Development of an action programme tackling obesity-related behaviours in adolescents: a participatory system dynamics approach.

System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10-14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system's structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.

Understanding the system dynamics of obesity-related behaviours in 10- to 14-year-old adolescents in Amsterdam from a multi-actor perspective.

Introduction and Methods: To develop an understanding of the dynamics driving obesity-related behaviours in adolescents, we conducted systems-based analysis on a causal loop diagram (CLD) created from a multi-actor perspective, including academic researchers, adolescents and local stakeholders. Results: The CLD contained 121 factors and 31 feedback loops. We identified six subsystems with their goals: (1) interaction between adolescents and the food environment, with profit maximisation as goal, (2) interaction between adolescents and the physical activity environment, with utility maximisation of outdoor spaces as goal, (3) interaction between adolescents and the online environment, with profit maximisation from technology use as goal, (4) interaction between adolescents, parenting and the wider socioeconomic environment, with a goal focused on individual parental responsibility, (5) interaction between healthcare professionals and families, with the goal resulting in treating obesity as an isolated problem, and (6) transition from childhood to adolescence, with the goal centring around adolescents' susceptibility to an environment that stimulates obesity-related behaviours. Discussion: Analysis showed that inclusion of the researchers' and stakeholders' perspectives contributed to an understanding of how the system structure of an environment works. Integration of the adolescents' perspective enriched insights on how adolescents interact with that environment. The analysis further showed that the dynamics driving obesity-related behaviours are geared towards further reinforcing such behaviours.

Is the transition from primary to secondary school a risk factor for energy balance-related behaviours? A systematic review.

OBJECTIVE: The substantial changes in the physical and social environment during the transition from primary to secondary school may significantly impact adolescents' energy balance-related behaviours (i.e. dietary behaviour, sedentary behaviour, sleep behaviour and physical activity (PA)). This is the first review systematically summarising evidence on changes in four energy balance-related behaviours of adolescents across the school transition from primary to secondary school. DESIGN: For this systematic review, the electronic databases Embase, PsycINFO and SPORTDiscus were searched for relevant studies from inception to August 2021. PubMed was searched for relevant studies from inception to September 2022. Inclusion criteria were: (i) longitudinal studies reporting; (ii) one or more energy balance-related behaviours; and (iii) across the school transition, that is, with measurement(s) during both primary and secondary school. SETTING: Transition from primary to secondary school. PARTICIPANTS: Adolescents across the transition from primary to secondary school. RESULTS: Thirty-four studies were eligible. We found strong evidence for an increase in sedentary time, moderate evidence for a decrease in fruit and vegetable consumption, and inconclusive evidence for a change in total, light, and moderate-to-vigorous PA, active transport, screen time, unhealthy snack consumption, and sugar-sweetened beverages consumption among adolescents across the school transition. CONCLUSIONS: During the transition from primary to secondary school, sedentary time and fruit and vegetable consumption tend to change unfavourably. More high-quality, longitudinal research is needed specifically on changes in energy balance-related behaviour across the school transition, especially regarding sleep behaviour. (Prospero registration: CRD42018084799).

Understanding obesity-related behaviors in youth from a systems dynamics perspective: The use of causal loop diagrams.

This paper reports how we applied systems dynamics methods to gain insight into the complexity of obesity-related behaviors in youth, including diet, physical activity, sedentary behavior, and sleep, by integrating a literature review into causal loop diagrams (CLDs). Results showed that the CLDs consisted of multiple subsystems and three types of dynamics appeared, including (1) feedback loops, (2) connections between feedback loops and subsystems, and (3) mechanisms. We observed clear similarities in the dynamics for the four behaviors in that they relate to "traditional" subsystems, such as home and school environments, as well as to newly added subsystems, including macroeconomics, social welfare, and urban systems. The CLDs provided insights that can support the development of intervention strategies, including (1) the confirmation that a range of mechanisms cover and connect multiple levels and settings, meaning that there is no silver bullet to address obesity; (2) understanding of how interventions in one particular setting, such as school, might be influenced by the interactions with other settings, such as urban systems; and (3) a comprehensive view of (un)intended consequences. This way of framing the problem will assist moving towards public health interventions that respond to and operate in the complexity of the real world.

A System Dynamics and Participatory Action Research Approach to Promote Healthy Living and a Healthy Weight among 10-14-Year-Old Adolescents in Amsterdam: The LIKE Programme.

This paper describes the design of the LIKE programme, which aims to tackle the complex problem of childhood overweight and obesity in 10-14-year-old adolescents using a systems dynamics and participatory approach. The LIKE programme focuses on the transition period from 10-years-old to teenager and was implemented in collaboration with the Amsterdam Healthy Weight Programme (AHWP) in Amsterdam-East, the Netherlands. The aim is to develop, implement and evaluate an integrated action programme at the levels of family, school, neighbourhood, health care and city. Following the principles of Participatory Action Research (PAR), we worked with our population and societal stakeholders as co-creators. Applying a system lens, we first obtained a dynamic picture of the pre-existing systems that shape adolescents' behaviour relating to diet, physical activity, sleep and screen use. The subsequent action programme development was dynamic and adaptive, including quick actions focusing on system elements (quick evaluating, adapting and possibly catalysing further action) and more long-term actions focusing on system goals and/or paradigm change. The programme is supported by a developmental systems evaluation and the Intervention Level Framework, supplemented with routinely collected data on weight status and health behaviour change over a period of five years. In the coming years, we will report how this approach has worked to provide a robust understanding of the programme's effectiveness within a complex dynamic system. In the meantime, we hope our study design serves as a source of inspiration for other public health intervention studies in complex systems.

The impact of mindfulness-based interventions on doctors' well-being and performance: A systematic review.

OBJECTIVES: The well-being of doctors is at risk, as evidenced by high burnout rates amongst doctors around the world. Alarmingly, burned-out doctors are more likely to exhibit low levels of professionalism and provide suboptimal patient care. Research suggests that burnout and the well-being of doctors can be improved by mindfulness-based interventions (MBIs). Furthermore, MBIs may improve doctors' performance (eg in empathy). However, there are no published systematic reviews that clarify the effects of MBIs on doctor well-being or performance to inform future research and professional development programmes. We therefore systematically reviewed and narratively synthesised findings on the impacts of MBIs on doctors' well-being and performance. METHODS: We searched PubMed and PsycINFO from inception to 9 May 2018 and independently reviewed studies investigating the effects of MBIs on doctor well-being or performance. We systematically extracted data and assessed study quality according to the Medical Education Research Study Quality Instrument (MERSQI), and narratively reported study findings. RESULTS: We retrieved a total of 934 articles, of which 24 studies met our criteria; these included randomised, (un)controlled or qualitative studies of average quality. Effects varied across MBIs with different training contents or formats: MBIs including essential mindfulness training elements, or employing group-based training, mostly showed positive effects on the well-being or performance of doctors across different educational and hospital settings. Doctors perceived both benefits (enhanced self- and other-understanding) and challenges (time limitations and feasibility) associated with MBIs. Findings were subject to the methodological limitations of studies (eg the use of self-selected participants, lack of placebo interventions, use of self-reported outcomes). CONCLUSIONS: This review indicates that doctors can perceive positive impacts of MBIs on their well-being and performance. However, the evidence was subject to methodological limitations and does not yet support the standardisation of MBIs in professional development programmes. Rather, health care organisations could consider including group-based MBIs as voluntary modules for doctors with specific well-being needs or ambitions regarding professional development.

Co-designing obesity prevention interventions together with children: intervention mapping meets youth-led participatory action research.

BACKGROUND: Youth-led Participatory Action Research (YPAR) involves children throughout the process of developing and implementing interventions. Combining YPAR with a structural approach for designing and planning interventions, such as Intervention Mapping (IM), may further improve implementation and effectiveness of interventions. This paper describes how YPAR and IM were combined in the Kids in Action study. METHODS: The Kids in Action study aims to improve health behaviors of 9-12-year old children living in a low socioeconomic neighborhood in Amsterdam, by co-designing interventions with these children. At each of four schools 6-8 children (N = 18-24 total per year) and two academic researchers formed participatory groups that met weekly or every fortnight during two school years. An IM expert panel advised the participatory groups on the application of IM. RESULTS: Following the IM protocol, we conducted a participatory needs assessment with children, parents and professionals, in IM-step 1. In IM-step 2, the IM expert panel constructed matrices of program objectives, and the children provided feedback. In collaboration with children programs were designed and produced using an iterative process during IM-steps 3-4. In IM-step 5, the participatory groups and professional community partners designed the implementation plan. Finally, in IM-step 6, the protocol of the process and effect evaluation - executed by academic researchers with input from children - was developed. CONCLUSIONS: By combining YPAR and IM, several interventions have been developed and implemented, varying from a school water policy to extracurricular sports activities. Sharing responsibility with children was challenging when combining IM with YPAR. In YPAR children are given as much autonomy as possible, while traditional IM development work is primarily done by academic researchers. Strengths in combining IM and YPAR include the involvement of the end-users - children - throughout the process while at the same time developing interventions based on existing evidence. Time-management, a multidisciplinary team, and flexibility are important conditions when combining IM with YPAR. A strong community project group, with professionals who were willing to help children develop and execute their ideas, was an important success factor. This study can serve as an example to other YPAR studies developing interventions using the IM protocol.