How healthy are the healthcare staff in a rural health service? A cross-sectional study.

Background: The COVID-19 pandemic has amplified the need to understand the health and wellbeing of healthcare workers in hospital settings. Crises like the COVID-19 pandemic create poor health outcomes for healthcare workers, yet little is understood about underlying patterns of modifiable health determinants. Objective: The aim of the study was to examine the health and wellbeing data of healthcare workers before and during the COVID-19 pandemic and inform future healthy intervention activities within the workplace. Design: Repeat cross-sectional study pre-2018 and mid-COVID-19 2020. Settings: Rural health service in Victoria, Australia. Participants: All 800 healthcare workers within the health service were invited; of these, 184 (23%) participated at Time 1 and 87 (11%) at Time 2. Methods: Diet, physical activity, sleep behaviours, and psychological distress were collected via online survey in Qualtrics. Pre-COVID-19 pandemic, anthropometry (height, weight, waist circumference, blood pressure), and type 2 diabetes risk were collected by a trained practitioner. However, to reduce burden on healthcare workers mid-COVID-19 pandemic, only self-reported anthropometry was collected. Results: The majority of participants were Australian-born females (84% at both timepoints) with half over the age of 45 (63% Time 1, 53% Time 2). Around half worked part-time (49% Time 1, 54% Time 2), over a third full-time (39% Time 1, 36% Time 2), and the majority reported working regular day shifts in the past 3 months (70% Time 1, 65% Time 2). Among this sample, there were few smokers (9% Time 1, 7% Time 2), and two thirds of participants were living with overweight or obesity (64% Time 1, 67% Time 2). Across both time points, compliance with health guidelines was low; 41% (Time 1) and 42% (Time 2) met fruit, 17% (Time 1) and 12% (Time 2) met vegetable, and just under 50% met physical activity guidelines at both time points. Those reporting moderate to very high levels of psychological stress increased from 42% (Time 1) to 59% (Time 2) (p< 0.05). At Time 1, >80% were at intermediate (39%) or high (33%) risk of developing type 2 diabetes within the next 5 years; and a third (32%) were hypertensive. Reasons for physical inactivity at work included already exercising out-of-work hours (28%), living too far from work (18%), available time (9%), and inflexible work hours (8%). Conclusions: Several high-risk health areas along with opportunities for supporting improved wellbeing were identified in this group of healthcare workers. Psychological distress of healthcare workers urgently needs to be addressed, and this is reinforced by the need to understand the longitudinal impact of COVID-19 on the health and wellbeing of healthcare workers. Workplace settings, such as a health service, is an ideal setting to invest in healthcare workers with individual, organisational, and broader community benefits.

The common drivers of children and young people's health and wellbeing across 13 local government areas: a systems view.

BACKGROUND: System dynamics approaches, including group model building (GMB) and causal loop diagrams (CLDs), can be used to document complex public health problems from a community perspective. This paper aims to apply Social Network Analysis (SNA) methods to combine multiple CLDs created by local communities into a summary CLD, to identify common drivers of the health and wellbeing of children and young people. METHODS: Thirteen community CLDs regarding children and young people health and wellbeing were merged into one diagram involving three steps: (1) combining variable names; (2) CLD merging, where multiple CLDs were combined into one CLD with a set of unique variables and connections; (3) paring, where the Decision-Making Trial and Evaluation Laboratory (DEMATEL) method was used to generate a cut-point to reduce the number of variables and connections and to rank the overall importance of each variable in the merged CLD. RESULTS: Combining variable names resulted in 290 variables across the 13 CLDS. A total of 1,042 causal links were identified in the merged CLD. The DEMATEL analysis of the merged CLD identified 23 common variables with a net importance between 1.0 and 4.5 R + C values and 57 causal links. The variables with the highest net importance were 'mental health' and 'social connection & support' classified as high net receivers of influence within the system. CONCLUSIONS: Combining large CLDs into a simple diagram represents a generalisable model of the drivers of complex health problems.

Potential Mediating Roles of Children's Health-Related Quality of Life and Weight-Related Behaviors in the Relationship Between Socio-Educational Advantage and Weight Status.

Background: Socioeconomic status is inversely associated with weight status in developed countries. Underlying mechanisms are still to be clarified. Our aim was to determine if weight-related behaviors and health-related quality of life (HRQoL) mediate the relationship between socio-educational advantage and weight status in Australian children 9 to 13 years of age. Methods: Secondary analysis of data collected by two cluster randomized trials (2019 wave). We measured children's (n = 3978) height, weight, diet, physical activity, sedentary behavior, and HRQoL. Socio-.educational advantage was assessed at school level using the Index of Community Socio-Educational Advantage (ICSEA). A counterfactual framework was used to explore potential mediators in the relationship between socio-educational disadvantage and (1) overweight/obesity and (2) BMI z-score (BMIz). Results: Low socio-educational advantage was associated with increased overweight/obesity and BMIz. The overweight/obesity association was mediated by sedentary behavior (natural indirect effect as a proportion of total, 7.5%) sugar-sweetened beverage (SSB) consumption (12.7%), physical functioning (11.9%), psychosocial health (10.9%), school (6.8%) and social functioning (15.6%), and total HRQoL score (13.8%). The ICSEA-BMIz relationship was mediated by sedentary behavior (5.7%), sleep duration (4.1%), SSB (10.6%), physical functioning (9.9%), psychosocial health (9.1%), school (5.5%) and social (13.7%) functioning, and total HRQoL score (11.7%). Conclusion: Victorian Children with low socio-educational advantage were more likely to be living with overweight or obesity. This relationship was mediated by children's sedentary behavior, SSB consumption, and HRQoL. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616000980437 (registered July 26, 2016, retrospectively registered) and ACTRN12618001986268 (registered December 11, 2018, prospectively registered). https://www.anzctr.org.au/Trial/Registration.

Systems thinking in local government: intervention design and adaptation in a community-based study.

BACKGROUND: Systems thinking approaches are increasingly being used by communities to address complex chronic disease. This paper reports on the VicHealth Local Government Partnership (VLGP) which sought to co-create improvements in the health and well-being of children and young people by working with local government in Victoria, Australia. METHODS: The VLGP included a series of health promotion modules, aimed at creating policy, programme and practice changes across local government. One of these modules, Connecting the Dots - creating solutions for lasting change, aimed to build capacity for systems thinking in municipal public health and well-being planning across 13 councils. The approach was adapted and data were collected on the stimuli for, and results of, adaptation. RESULTS: The council adapted the systems thinking approach to meet geographic characteristics, priority health issue/s and participant target group needs. Adaptions applied to workshop materials, training delivery, existing and new resources, and to align with other community-based approaches. Stimuli for adaptation included the COVID-19 pandemic, needs of children and young people, capacity of council to deliver the workshop series, and time available within the project or for the participant group. CONCLUSIONS: Systems thinking was used and adapted by councils to improve the health and well-being of children and young people and increase the voices of children and young people in decision-making. Flexible delivery is critical to ensure communities can adapt the approach to meet local needs.

Combining systems thinking approaches and implementation science constructs within community-based prevention: a systematic review.

BACKGROUND: Systems science offers methods for designing population health interventions while implementation science provides specific guidance for successful implementation. Integrating systems and implementation science may strengthen implementation and enhance and sustain systemic change to achieve system-level outcomes. Little is known about the extent to which these two approaches have been integrated to date. This review aimed to identify and synthesise the peer-reviewed literature that has reported the combined use of systems thinking approaches and implementation science constructs (within the same study), to deliver population health interventions. METHODS: A systematic literature search of peer-reviewed original research was conducted across six databases from 2009 to 2021. Journal manuscripts were included if they: (1) reported on a population health study conducted in a community, (2) reported the use of a systems method in the design of the intervention, and (3) used an implementation science theory, framework or model in the delivery of the intervention. Data extracted related to the specific systems methods and definitions and implementation science constructs used. The Mixed Methods Appraisal Tool (MMAT) was used to assess study quality. RESULTS: Of the 9086 manuscripts returned, 320 manuscripts were included for full-text review. Of these, 17 manuscripts that reported on 14 studies were included in the final extraction. The most frequently reported systems methods were a 'whole of community systems approach' (n = 4/14) and 'community-based system dynamics' (n = 2/14). Nineteen different implementation science theories, frameworks and models were used for intervention delivery, with RE-AIM being the only framework used in more than one study. CONCLUSION: There are few published peer-reviewed studies using systems thinking and implementation science for designing and delivering population health interventions. An exploration of synergies is worthwhile to operationalise alignment and improve implementation of systems thinking approaches. Review protocol registration PROSPERO CRD42021250419.

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

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

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

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

Measuring Shifts in Mental Models in the Prevention of Childhood Obesity in Rural Australia.

Group model building is a participatory workshop technique used in system dynamics for developing community consensus to address complex problems by consensus building on individual assumptions. This study examines changes in individual mental models of the complex problem of childhood obesity following participation in group model building (GMB), as part of a larger community-based system dynamics project. Data are drawn from GMB participants across six community sites in the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS) in rural and regional Victoria, Australia. Each community participated in two GMB sessions resulting in a causal loop diagram (CLD) of drivers of childhood obesity for each community. Presurvey and postsurvey captured participants' perspectives before and after (n = 25) participation in both GMB sessions and a blend of inductive and deductive qualitative content analysis was used to code individual responses. Three calculations were used to determine the number of responses, whether responses were a result of persuasion from others, and comparison of responses to those found in the CLD. Our study found participant mental models shifted during the course of the GMB sessions, with some responses persuaded by others and 75% of new insights identified in CLDs created by communities. The GMB process created a platform for participants to share ideas and learn from each other. In addition, participants listed new insights about childhood obesity in their community through developing CLDs.

Four-Year Accelerometry Outcomes from a Cluster Randomized Whole of Systems Trial of Prevention Strategies for Childhood Obesity.

Background: We investigated the effect of the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS) intervention on children's objectively measured physical activity and sedentary time (ST). Methods: We conducted a cluster randomized controlled trial with children in grades 4 (∼9-10 years old) and grade 6 (∼11-12 years old) from 10 communities in the Great South Coast region of Victoria, Australia. Communities were randomly allocated (1:1) to receive the WHO STOPS intervention in 2015. WHO STOPS was a whole of community systems-based approach to preventing childhood obesity. Outcome data were collected using a repeat cross-sectional design in 2015, 2017, and 2019. Children were asked to wear a hip-mounted accelerometer for 7 days. Age-specific Axis 1 activity counts were converted into duration (minutes/day) spent engaged in moderate-to-vigorous physical activity (MVPA), light physical activity (LPA), and ST. Linear mixed regression models were fitted to estimate the effects of the intervention on the three activity outcomes across the study period. Results: Analyses were based on valid accelerometer data from 1406 children (intervention n = 745; control n = 661). Results for MVPA, LPA, and ST were nonsignificant. Between 2015 and 2017, there were positive, but nonsignificant, changes in mean MVPA favoring intervention boys [3.7 minutes/day; 95% confidence interval (CI): -5.7 to 13.1] and girls (5.5 minutes/day; 95% CI: -1.5 to 12.6). By 2019, these effects had attenuated. Conclusions: Although the WHO STOPS intervention did not significantly change activity levels, the magnitudes of the effects on MVPA suggest that further research with whole-of-community interventions in larger samples would be worthwhile. Clinical trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR.org.au) identifier 12616000980437.

System approaches to childhood obesity prevention: ground up experience of adaptation and real-world context.

OBJECTIVE: Childhood obesity prevention is critical to reducing the health and economic burden currently experienced by the Australian economy. System science has emerged as an approach to manage the complexity of childhood obesity and the ever-changing risk factors, resources and priorities of government and funders. Anecdotally, our experience suggests that inflexibility of traditional research methods and dense academic terminology created issues with those working in prevention practice. Therefore, this paper provides a refined description of research-specific terminology of scale-up, fidelity, adaptation and context, drawing from community-based system dynamics and our experience in designing, implementing and evaluating non-linear, community-led system approaches to childhood obesity prevention. DESIGN: We acknowledge the importance of using a practice lens, rather than purely a research design lens, and provide a narrative on our experience and perspectives on scale-up, fidelity, context and adaptation through a practice lens. SETTING: Communities. PARTICIPANTS: Practice-based researcher experience and perspectives. RESULTS: Practice-based researchers highlighted the key finding that community should be placed at the centre of the intervention logic. This allowed communities to self-organise with regard to stakeholder involvement, capacity, boundary identification, and co-creation of actions implemented to address childhood obesity will ensure scale-up, fidelity, context and adaptation are embedded. CONCLUSIONS: We need to measure beyond primary anthropometric outcomes and focus on evaluating more about implementation, process and sustainability. We need to learn more from practitioners on the ground and use an implementation science lens to further understand how actions work. This is where solutions to sustained childhood obesity prevention will be found.

Building capacity for the use of systems science to support local government public health planning: a case study of the VicHealth Local Government Partnership in Victoria, Australia.

OBJECTIVE: To present an approach to build capacity for the use of systems science to support local communities in municipal public health and well-being planning. DESIGN: Case study. SETTING: Local government authorities participating in the VicHealth Local Government Partnership in Victoria, Australia. PARTICIPANTS: Local government staff members were trained in community-based system dynamics (CBSD), and group model building (GMB) techniques to mobilise local community efforts. The trained local government facilitation teams then delivered GMB workshops to community stakeholder groups from 13 local government areas (LGA)s. MAIN OUTCOMES: Training in CBSD was conducted with council facilitation teams in 13 LGAs, followed by the local delivery of GMB workshops 1-3 to community stakeholders. Causal loop diagrams (CLD) representing localised drivers of mental well-being, healthy eating, active living or general health and well-being of children and young people were developed by community stakeholders. Locally tailored action ideas were generated such as well-being classes in school, faster active transport and access to free and low-cost sporting programmes RESULTS: Overall, 111 local government staff participated in CBSD training. Thirteen CLDs were developed, with the stakeholders that included children, young people and community members, who had participated in the GMB workshops across all 13 council sites. Workshop 3 had the highest total number of participants (n=301), followed by workshop 1 (n=287) and workshop 2 (n=171). CONCLUSIONS: Local facilitation of the CBSD process has developed community informed and locally relevant CLDs that will be used to lead local action to improve the well-being of children and young people. Training employees in CBSD is one approach to increase systems thinking capacity within local government.

System dynamics modelling to engage community stakeholders in addressing water and sugar sweetened beverage consumption.

BACKGROUND: Participatory approaches to develop community-based system dynamics models to tackle complexity are promising, but research is needed in how simulation models can be developed with community stakeholders to yield significant system insights. This study presents the results of a community-based system dynamics modelling process to increase water consumption and decrease sugar sweetened beverage consumption in Portland, Victoria, a regional town in Australia. METHODS: A series of group model building workshops with 11 community stakeholders addressing the topic of water and sugar sweetened beverage consumption was conducted in Portland. A simulating system dynamics model was built with stakeholders to inform action planning. RESULTS: A system dynamics model was created to provide insight into water and sugar sweetened beverage consumption in Portland. The model included six feedback loops describing the causal effects of sugar sweetened beverage consumption habits and norms, water taste, water consumption norms, public water availability, and public health benefits. For example, the sugar sweetened beverage consumption norm loop modelled how people overestimating others' consumption may motivate an increase in their own consumption, feeding back and further amplifying an increase in sugar sweetened beverage consumption. The model contributed to the foundation of a strong partnership to improve the taste of water and educate the public on water consumption. CONCLUSIONS: Engaging stakeholders in system dynamics modelling about water and sugar sweetened beverage consumption increased engagement and collaboration to address the problem among community stakeholders.

Healthy weight, health behaviours and quality of life among Aboriginal children living in regional Victoria.

OBJECTIVE: To report the prevalence of healthy weight and related behaviours among Victorian Aboriginal and non-Aboriginal children and explore associations between these factors and health-related quality of life (HRQoL). METHODS: Analysis of cross-sectional data from two cluster randomised controlled trials using logistic and linear mixed models. The sample included Aboriginal (n=303) and non-Aboriginal (n=3,026) children aged 8-13 years. RESULTS: More than two-thirds of Aboriginal children met guidelines for fruit (75.9%), sweetened drinks (66.7%), sleep (73.1%), screen time (67.7%) and objectively measured physical activity (83.6%); and 79.1% reported consuming take-away foods less than once per week. Aboriginal children were more likely to meet vegetable consumption guidelines (OR=1.42, 95%CI: 1.05, 1.93), but less likely to have a healthy weight (OR=0.66, 95%CI: 0.52, 0.85) than non-Aboriginal children. Mean HRQoL scores were significantly higher among non-Aboriginal children and both Aboriginal and non-Aboriginal children meeting health guidelines. CONCLUSIONS: Most Aboriginal children in this study met guidelines for fruit, physical activity, screen time and sleep, and those meeting these guidelines had significantly higher HRQoL. IMPLICATIONS FOR PUBLIC HEALTH: Promoting nutrition, physical activity and sleep is likely to benefit all children. Aboriginal community-controlled organisations can use these data to design culturally-specific programs that may improve disparities in healthy weight and HRQoL.

Generating change through collective impact and systems science for childhood obesity prevention: The GenR8 Change case study.

BACKGROUND: Community-based interventions have shown promise in reducing childhood overweight and obesity. However, they have been critiqued for using linear logic models. Participatory community-based systems approaches are posited as addressing the complexity of non-linear relationships in a local context. Community members are empowered to understand and describe obesity causation, identify and prioritise possible solutions. The application of such approaches to childhood obesity is in its infancy. AIM: To describe the first 12 months of a participatory whole-of-community systems approach to creating collective action to tackle childhood obesity, called GenR8 Change, in a local government area of Victoria, Australia. METHODS: Three group model building (GMB) sessions focused on the development of a causal loop diagram (CLD), prioritised evidence-informed actions, and developed implementation strategies. The collective impact framework underpinned the approach, with a local backbone group supporting community members to implement prioritised actions. RESULTS: The first two GMB sessions included 20 key community leaders where a CLD examining the factors contributing to childhood obesity in the community was constructed and refined (22 variables GMB1, 53 variables GMB2). In the third session, 171 members of the wider community further refined the CLD, identified priorities for childhood obesity prevention (72 variables in final CLD). One-hundred and thirteen individuals signed up across 13 working groups to plan and implement 53 prioritised actions. Agreed community actions included creating sugar free zones; developing healthy policies; increasing breastfeeding rates; improving drinking water access; and increasing physical activity options. Twelve months post-GMB3, 115 actions had been implemented. CONCLUSION: GenR8 Change is one of the first communities to apply systems thinking to childhood obesity prevention. Knowledge on how to collectively identify relevant leverage points to tackle childhood obesity can now be shared with other communities.

Describing workplace interventions aimed to improve health of staff in hospital settings - a systematic review.

BACKGROUND: A large proportion of staff working in hospital settings are overweight or obese, have poor dietary habits and low physical activity levels. The workplace is a priority setting for health promotion. This systematic review will describe dietary and physical activity workplace interventions that have aimed to improve the health of staff in hospital settings; and the barriers and enablers of implementing these interventions. METHODS: A systematic search retrieved 551 studies from 2004 to 2020 using the following databases CINAHL Complete, MEDLINE Complete, Academic Search Complete, Global Health, Health Source Nursing/Academic Edition and PsycINFO. Studies were included if they: (1) took place in a hospital setting; (2) employed a physical activity or dietary intervention to improve the well-being of staff; (3) the intervention duration was 12 weeks or over; (4) used a control group. The Integrated quality Criteria for the Review of Multiple Study designs (ICROMS) and National Institute of Health's National Heart Lung and Blood Institute Quality Assessment Tools for Observational Cohort and Cross-Sectional Studies tools were used to assess quality of included studies. A narrative review was conducted. RESULTS: Quality analysis identified six studies of high quality, nine moderate quality, and three low quality. Of these 18 studies, 15 reported at least one positive health outcome. The evidence revealed that multi-component strategies, financial incentives and motivational strategies were the most effective approaches to improve health behaviours of hospital staff. CONCLUSION: Hospital-based dietary and physical activity workplace interventions show promise as an effective strategy for improving health behaviours of hospital staff. Methodological limitations highlight the need for more research from high-quality, randomised control trials, to gain further insight into the benefits of workplace interventions in hospital settings.

The Public Health 12 framework: interpreting the 'Meadows 12 places to act in a system' for use in public health.

BACKGROUND: Systems science approaches have demonstrated effectiveness in identifying underlying drivers of complex problems and facilitating the emergence of potential interventions that are locally tailored, feasible, sustainable and evidence informed. Despite the potential usefulness of system dynamics simulation modelling and other systems science modelling techniques in guiding implementation, time and cost constraints have limited its ability to provide strong guidance on how to implement complex interventions in communities. Guidance is required to ensure systems interventions lead to impactful systems solutions, implemented utilising strategies from the intersecting fields of systems science and implementation science. To provide cost-effective guidance on how and where to implement in systems, we offer a translation of the 'Meadows 12 places to act in a system' (Meadows 12) into language useful for public health. METHODS: This translation of Meadows 12 was informed by our experience in working with 31 communities across two complex large scale randomised control trials and one large whole of community case study. These research projects utilised systems science and implementation science to co-create childhood obesity prevention interventions. The team undertaking this translation comprised research academics, implementation specialists and practitioners, practice-based researchers and a systems dynamicist. Our translation of each of the Meadows 12 levels to act in the system maintains the fidelity and nuance of the 12 distinct levels. We provide examples of each level of the Public Health 12 framework (PH12) drawn from 31 communities. All research was conducted in Victoria, Australia between 2016 and 2020. RESULTS: PH12 provides a framework to guide both research and practice in real world contexts to implement targeted system level interventions. PH12 can be used with existing implementation science theory to identify relevant strategies for implementation of these interventions to impact the system at each of the leverage points. CONCLUSION: To date little guidance for public health practitioners and researchers exists regarding how to implement systems change in community-led public health interventions. PH12 enables operationalisation Meadows 12 systems theory into public health interventions. PH12 can help research and practice determine where leverage can be applied in the system to optimise public health systems level interventions and identify gaps in existing efforts. TRIAL REGISTRATION: WHO STOPS: ANZCTR: 12616000980437 . RESPOND: ANZCTR: 12618001986268p .

Relationship between "Blue Space" Proximity and Children's Weight Status, Health Behaviors, and Health-Related Quality of Life among a Sample of Regional Victorian Primary School Children.

Background: Access to green space (e.g., parks and gardens) has been associated with child health and wellbeing, whereas blue space (e.g., coasts, lakes, and rivers) is understudied. Our aim was to determine whether proximity to the coast was associated with primary school children's weight status, modifiable health-related behaviors, and health-related quality of life (HRQoL). Methods: Exploratory cross-sectional analysis of baseline data from the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHOSTOPS) study, to estimate gender-specific differences in weight and behaviors across four bands of distance from the coast (<5 km, 5 to <25 km, 25 to <50 km, ≥50 km). Linear and logistic models, with robust standard errors, adjusted for school year level, area-level socioeconomic position and rurality, and allowing for distance by gender interaction were fitted on data from 1216 children (aged 8.5-13 years). Main outcomes were weight status (categorical), physical activity (PA) (categorical), and global HRQoL score (continuous). Results: Compared with girls living in towns ≥50 km from the coast, those living within 5 km had lower odds for overweight/obesity [odds ratio (OR) = 0.50; 95% confidence interval (CI): 0.37-0.67] and higher mean moderate-to-vigorous PA minutes (accelerometry) (ß = 8.7; 95% CI: 2.0-15.5) and global HRQoL (ß = 3.2; 95% CI: 1.4-5.0). Compared with boys living ≥50 km from the coast, those living within 5 km had higher odds of meeting self-reported PA guidelines (≥60 minutes/day) for ≥5 days (OR = 2.33; 95% CI: 1.75-3.10), and higher mean global HRQoL scores (ß = 5.6; 95% CI: 1.9-9.3). Conclusions: Living close to the coast was associated with some favorable health outcomes and behaviors, which differed between girls and boys.

A Theory of Change for Community-Based Systems Interventions to Prevent Obesity.

INTRODUCTION: Applying systems science in public health trials is a recent innovation in childhood obesity prevention. This paper aims to use systems science conventions to propose a theory of change for community-based interventions aiming to build capacity and use exemplars from systems science for obesity prevention to describe how this approach works. METHODS: Participants were community-based researchers. A dynamic hypothesis was created in workshops conducted in 2020 and 2021 by identifying variables critical to building community capacity for systems thinking. These were used to develop stock and flow diagrams representing individual causal relationships, feedback loops, and the overall theory of change. RESULTS: The resultant model identified 9 stocks and 4 pairs of central balancing and reinforcing feedback loops. These represented building commitment through relationships, mutual learning, strengthening collaboration, and embedding capacity. The model is described using examples from 3 trials involving 25 communities across Victoria, Australia. CONCLUSIONS: This nonlinear and practice-based model illustrates the process of community-based obesity prevention. The model integrates >20 years of community-based intervention implementation experience, providing an overarching theory of how such interventions work to create change and prevent obesity.

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

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