Healthy together Victoria and childhood obesity study: effects of a large scale, community-based cluster randomised trial of a systems thinking approach for the prevention of childhood obesity among secondary school students 2014-2016.

BACKGROUND: Healthy Together Victoria (HTV) was a Victorian Government initiative that sought to reduce the prevalence of overweight and obesity through targeting chronic disease risk factors including physical activity, poor diet quality, smoking, and harmful alcohol use. The intervention involved a boosted workforce of > 170 local-level staff in 12 communities; employed to deliver system activation around health and wellbeing for individuals, families and communities. A cluster randomised trial (CRT) of a systems thinking approach to obesity prevention was embedded within HTV. We present the two-year changes in overweight and obesity and associated behaviours among secondary school students across Victoria, Australia. METHODS: Twenty-three geographically bounded areas were randomised to intervention (12 communities) or comparison (11 communities). Randomly selected secondary schools within each community were invited to participate in the trial in 2014 and 2016. Students in Grade 8 (aged approximately 13-15 years) and Grade 10 (aged approximately 15-16 years) at participating schools were recruited using an opt-out approach across July-September 2014 and 2016. Primary outcomes were body mass index (BMI) and waist circumference. Secondary outcomes were physical activity, sedentary behaviour, diet quality, health-related quality of life, and depressive symptoms. Linear mixed models were fit to estimate the intervention effect adjusting for child/school characteristics. RESULTS: There were 4242 intervention children and 2999 control children in the final analysis. For boys, the two-year change showed improvement in intervention versus control for waist circumference (difference in change: - 2.5 cm; 95% confidence interval [CI]: - 4.6, - 0.5) and consumption of sugar-sweetened beverages per day (< 1 serve: 8.5 percentage points; 95% CI: 0.6, 16.5). For girls, there were no statistically significant differences between conditions. CONCLUSIONS: HTV seemed to produce favourable changes in waist circumference and sugar-sweetened beverage consumption for boys, however, no effect on BMI was observed. Although the HTV intervention was cut short, and the period between data collection points was relatively short, the changes observed in HTV contribute to the growing evidence of whole-of-community interventions targeting childhood obesity. TRIAL REGISTRATION: This trial is unregistered. The intervention itself was a policy setting delivered by government and our role was the collection of data to evaluate the effect of this natural experiment. That is, this study was not a trial from the classical point of view and we were not responsible for the intervention.

National nutrition surveillance programmes in 18 countries in South-East Asia and Western Pacific Regions: a systematic scoping review.

Objective: To identify and analyse ongoing nutrition-related surveillance programmes led and/or funded by national authorities in countries in South-East Asian and Western Pacific Regions. Methods: We systematically searched for publications in PubMed® and Scopus, manually searched the grey literature and consulted with national health and nutrition officials, with no restrictions on publication type or language. We included low- and middle-income countries in the World Health Organization South-East Asia Region, and the Association of Southeast Asian Nations and China. We analysed the included programmes by adapting the United States Centers for Disease Control and Prevention's public health surveillance evaluation framework. Findings: We identified 82 surveillance programmes in 18 countries that repeatedly collect, analyse and disseminate data on nutrition and/or related indicators. Seventeen countries implemented a national periodic survey that exclusively collects nutrition-outcome indicators, often alongside internationally linked survey programmes. Coverage of different subpopulations and monitoring frequency vary substantially across countries. We found limited integration of food environment and wider food system indicators in these programmes, and no programmes specifically monitor nutrition-sensitive data across the food system. There is also limited nutrition-related surveillance of people living in urban deprived areas. Most surveillance programmes are digitized, use measures to ensure high data quality and report evidence of flexibility; however, many are inconsistently implemented and rely on external agencies' financial support. Conclusion: Efforts to improve the time efficiency, scope and stability of national nutrition surveillance, and integration with other sectoral data, should be encouraged and supported to allow systemic monitoring and evaluation of malnutrition interventions in these countries.

New insights in the mechanisms of weight-loss maintenance: Summary from a Pennington symposium.

Obesity is a chronic disease that affects more than 650 million adults worldwide. Obesity not only is a significant health concern on its own, but predisposes to cardiometabolic comorbidities, including coronary heart disease, dyslipidemia, hypertension, type 2 diabetes, and some cancers. Lifestyle interventions effectively promote weight loss of 5% to 10%, and pharmacological and surgical interventions even more, with some novel approved drugs inducing up to an average of 25% weight loss. Yet, maintaining weight loss over the long-term remains extremely challenging, and subsequent weight gain is typical. The mechanisms underlying weight regain remain to be fully elucidated. The purpose of this Pennington Biomedical Scientific Symposium was to review and highlight the complex interplay between the physiological, behavioral, and environmental systems controlling energy intake and expenditure. Each of these contributions were further discussed in the context of weight-loss maintenance, and systems-level viewpoints were highlighted to interpret gaps in current approaches. The invited speakers built upon the science of obesity and weight loss to collectively propose future research directions that will aid in revealing the complicated mechanisms involved in the weight-reduced state.

Cultural adaptations and methodological innovations to group model building for the systems actions to reduce malnutrition in all its forms in Southeast Asian countries and China (SYSTAM CHINA-SEACS International Consortium) project.

BACKGROUND: Group Model Building (GMB) is a participatory system dynamics method increasingly used to address complex public health issues like obesity. GMB represents a set of well-defined steps to engage key stakeholders to identify shared drivers and solutions of a given problem. However, GMB has not yet been applied specifically to develop multi-duty interventions that address multiple inter-related issues such as malnutrition in all its forms (MIAIF). Moreover, a recent systematic review of empirical applications of a systems approach to developing obesity interventions found no published work from non-western, low- and middle-income countries (LMICs). In this paper we describe adaptations and innovations to a common GMB process to co-develop systemic MIAIF interventions with Chinese decision-makers. METHODS: We developed, piloted and implemented multiple cultural adaptations and two methodological innovations to the commonly used GMB process in Fang Cheng Gang city, China. We included formal, ceremonial and policy maker engagement events before and between GMB workshops, and incorporated culturally tailored arrangements during participant recruitment (officials of the same seniority level joined the same workshop) and workshop activities (e.g., use of individual scoring activities and hand boards). We made changes to the commonly used GMB activities which enabled mapping of shared drivers of multiple health issues (in our case MIAIF) in a single causal loop diagram. We developed and used a 'hybrid' GMB format combining online and in person facilitation to reduce travel and associated climate impact. RESULTS: Our innovative GMB process led to high engagement and support from decision-makers representing diverse governmental departments across the whole food systems. We co-identified and prioritised systemic drivers and intervention themes of MIAIF. The city government established an official Local Action Group for long-term, inter-departmental implementation, monitoring and evaluation of the co-developed interventions. The 'hybrid' GMB format enabled great interactions while reducing international travel and mitigating limitations of fully online GMB process. CONCLUSIONS: Cultural and methodological adaptations to the common GMB process for an Asian LMIC setting were successful. The 'hybrid' GMB format is feasible, cost-effective, and more environmentally friendly. These cultural adaptations could be considered for other Asian settings and beyond to address inter-related, complex issues such as MIAIF.

Priority setting for non-communicable disease prevention - Co-producing a regulatory agenda informing novel codes of practice in Australia.

There are a range of priority setting methods for non-communicable disease (NCDs) prevention. However, existing methods are often designed without detailed consideration of local context and political economy- critical success factors for implementation. In Australia, codes of practice under state government Public Health Acts could be used for NCD prevention. To inform the potential development of codes of practice under Public Health Acts, this study aimed to co-create a priority setting framework that accounts for local context and the prevailing regulatory agenda. A priority setting framework was co-produced by a multidisciplinary technical advisory group consisting of government representatives, public health lawyers and academic experts. It incorporated general prioritisation criteria (evidence, cost-effectiveness, equity, burden of disease) and local contextual criteria (legal compatibility, unmet-needs, political acceptability, structural and technical feasibility, community support). The framework was then applied in practice through surveys and policy dialogue workshops to discuss political economy factors. Policies were limited to nutrition, alcohol and physical activity risk factors. Through the prioritisation process, the most impactful, feasible and acceptable policies for NCD prevention via state government codes of practice were: restrictions on in-store placement of unhealthy products, enhancing data systems and capabilities for health surveillance and implementation monitoring, removal of unhealthy foods and drinks sold and supplied in public institutions, prohibition of marketing of unhealthy foods and drinks on assets controlled by government, and implementation of subsidies or grants to increase fruit and vegetable intake. The process illustrated that explicit consideration of local context, legal compatibility and the political economy had a substantial influence on the prioritised list of actions. The proposed priority setting framework is designed to be flexible and adaptable to varying contexts, can be embedded in government processes or utilised by researchers and practitioners to co-produce a regulatory agenda that is locally relevant.

Comprehensive application of a systems approach to obesity prevention: a scoping review of empirical evidence.

A systems approach to obesity prevention is increasingly urged. However, confusion exists on what a systems approach entails in practice, and the empirical evidence on this new approach is unclear. This scoping review aimed to identify and synthesise studies/programmes that have comprehensively applied a systems approach to obesity prevention in intervention development, delivery/implementation, and evaluation. By searching international databases and grey literature, only three studies (10 publications) met inclusion criteria, which might be explained partially by suboptimal reporting. No conclusion on the effectiveness of this approach can be drawn yet due to the limited evidence base. We identified common features shared by the included studies, such as measuring ongoing changes, in addition to endpoint outcomes, and supporting capacity building. Some facilitators and barriers to applying a comprehensive systems approach in practice were identified. More well-designed and reported studies are needed, especially from low- and middle-income countries.

Health, wellbeing and nutritional impacts after 2 years of free school meals in New Zealand.

In 2020, a government-funded healthy school lunch program was introduced in a quarter of New Zealand schools, selected due to high levels of socio-economic barriers. This study assesses the impact of the introduction of the school lunch program from family (whanau), student and school principal perspectives. Across four schools, we conducted five focus groups (two with secondary students and three with family members) and four school principal interviews. Participating schools represented a range of contexts: primary and secondary, schools with cooks in on-site kitchens and schools receiving meals delivered by external caterers. Thematic analysis was used to develop themes describing the health, wellbeing and nutritional impact of the program. Family participants were 82% Indigenous Maori and self-identified as having 'borderline' (73.5%) or no financial security (8.8%). Seven positive impact themes were identified: improved food security, enhanced equity, increased appreciation of healthy foods for students, enhanced mana (wellbeing) for all, reduced financial hardship/stress for families, opportunities for nutritional learning and recognition that appreciation and uptake happen over time. Four negative impact themes were identified: low uptake that created food waste, perception that healthy food is not palatable for students, lack of knowledge of the program and loss of agency for students. This is the largest intervention in nutrition and food security for children implemented in New Zealand since the 1930's. The first 2 years have offered wellbeing and financial benefits for students and families, particularly when school environments promote uptake. More involvement of students and family members in the program planning is essential.

Building Culturally Centered System Dynamics Logic Models for the Brown Buttabean Motivation Organization: Protocol for a Systems Science Approach.

BACKGROUND: Brown Buttabean Motivation (BBM) is an organization providing support for Pacific people and Indigenous Maori to manage their weight, mainly through community-based exercise sessions and social support. It was started by DL, a man of Samoan and Maori descent, following his personal weight loss journey from a peak weight of 210 kg to less than half that amount. DL is a charismatic leader with a high media profile who is successful in soliciting donations from corporations in money and kindness. Over time, BBM's activities have evolved to include healthy eating, food parcel provision, and other components of healthy living. A co-design team of university researchers and BBM staff are evaluating various components of the program and organization. OBJECTIVE: The purpose of this study is to build culturally centered system dynamics logic models to serve as the agreed theories of change for BBM and provide a basis for its ongoing effectiveness, sustainability, and continuous quality improvements. METHODS: A systems science approach will clarify the purpose of BBM and identify the systemic processes needed to effectively and sustainably achieve the study's purpose. Cognitive mapping interviews with key stakeholders will produce maps of their conceptions of BBM's goals and related cause-and-effect processes. The themes arising from the analysis of these maps will provide the initial indicators of change to inform the questions for 2 series of group model building workshops. In these workshops, 2 groups (BBM staff and BBM members) will build qualitative systems models (casual loop diagrams), identifying feedback loops in the structures and processes of the BBM system that will enhance the program's effectiveness, sustainability, and quality improvement. The Pacific and Maori team members will ensure that workshop content, processes, and outputs are grounded in cultural approaches appropriate for the BBM community, with several Pacific and Maori frameworks informing the methods. These include the Samoan fa'afaletui research framework, which requires different perspectives to be woven together to create new knowledge, and kaupapa Maori-aligned research approaches, which create a culturally safe space to conduct research by, with, and for Maori. The Pacific fonofale and Maori te whare tapa wha holistic frameworks for interpreting people's dimensions of health and well-being will also inform this study. RESULTS: Systems logic models will inform BBM's future developments as a sustainable organization and support its growth and development beyond its high dependence on DL's charismatic leadership. CONCLUSIONS: This study will adopt a novel and innovative approach to co-designing culturally centered system dynamics logic models for BBM by using systems science methods embedded within Pacific and Maori worldviews and weaving together a number of frameworks and methodologies. These will form the theories of change to enhance BBM's effectiveness, sustainability, and continuous improvement. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN 12621-00093-1875; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382320. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/44229.

The utilisation of legal instruments by United Nations actors to restrict the exposure of children to unhealthy food and beverage marketing: a qualitative content analysis of UN instruments.

INTRODUCTION: United Nations (UN) agencies are influential global health actors that can introduce legal instruments to call on Member States to act on pressing issues. This paper examines the deployment and strength of global health law instruments used by UN actors to call on Member States to restrict the exposure of children to unhealthy food and beverage marketing. METHODS: Global health law instruments were identified from a review of four UN agencies that have a mandate over children's exposure to marketing of unhealthy food and beverage products namely: the World Health Organization (WHO); the Food and Agriculture Organization (FAO); the United Nations General Assembly (UNGA) and the UN Office of the High Commissioner for Human Rights (OHCHR). Data on marketing restrictions were extracted and coded and descriptive qualitative content analysis was used to assess the strength of the instruments. RESULTS: A wide range of instruments have been used by the four agencies: seven by the WHO; two by the FAO; three by the UNGA; and eight by the UN human rights infrastructure. The UN human rights instruments used strong, consistent language and called for government regulations to be enacted in a directive manner. In contrast, the language calling for action by the WHO, FAO and UNGA was weaker, inconsistent, did not get stronger over time and varied according to the type of instrument used. CONCLUSION: This study suggests that a child rights-based approach to restricting unhealthy food and beverage marketing to children would be supported by strong human rights legal instruments and would allow for more directive recommendations to Member States than is currently provided by WHO, FAO and UNGA. Strengthening the directives in the instruments to clarify Member States' obligations using both WHO and child rights mandates would increase the utility of global health law and UN actors' influence.

Caloric reductions needed to achieve obesity goals in Mexico for 2030 and 2040: A modeling study.

BACKGROUND: In Mexico, obesity prevalence among adults increased from 23% in 2000 to 36% in 2018, approximately. Mexico has not defined short- or long-term obesity goals, obscuring the level of effort required to achieve a relevant impact. We aimed to explore potential obesity goals for 2030 and 2040 in Mexico and to estimate the required caloric reductions to achieve them. METHODS AND FINDINGS: We obtained anthropometric and demographic information on the Mexican adult population (age ≥20 years) from the Health and Nutrition Surveys conducted in 2000, 2006, 2012, 2016, and 2018 (n = 137,907). Each survey wave is cross-sectional, multistage, and representative of the Mexican population at the national, regional, and urban/rural levels. Obesity prevalence was projected for 2030 and 2040 by combining population projections of energy intake by socioeconomic status (SES) with a weight-change microsimulation model taking into account individual-level information on sex, age, physical activity, and initial body weight and height. If current trends continue, Mexico's obesity prevalence is expected to increase from 36% (95% CI 35% to 37%) in 2018 to 45% (uncertainty interval [UI] 41% to 48%) in 2030 and to 48% (UI 41% to 55%) in 2040. Based on expert opinion, we identified 3 obesity goals scenarios: (1) plausible (38% in 2030 and 36% in 2040); (2) intermediate (33% in 2030 and 29% in 2040); and (3) ideal based on the average prevalence of Organization for Economic Co-operation and Development countries (OECD; 19%). We estimated the caloric reductions needed to achieve the goal scenarios using the microsimulation model. Obesity was projected to increase more rapidly in the low SES (around 34% in 2018 to 48% (UI 41% to 55%) in 2040), than in the middle (around 38% to 52% (UI 45% to 56%)), or high SES group (around 36% to 45% (UI 36% to 54%)). Caloric reductions of 40 (UI 13 to 60), 75 (UI 49 to 95), and 190 (UI 163 to 215) kcal/person/day would be needed to reach the plausible, intermediate, and the ideal (OECD) average scenarios for 2030, respectively. To reach the 2040 goals, caloric reductions of 74 (UI 28 to 114), 124 (UI 78 to 169), and 209 (UI 163 to 254) kcal/person/day would be required, respectively. Study limitations include assuming a constant and sedentary physical activity level, not considering cohort-specific differences that could occur in the future, and assuming the same caloric trends under no intervention and the obesity goal scenarios. CONCLUSIONS: To reach the 3 obesity goals in 2040, caloric reductions between 74 and 209 kcal/day/person would be needed in Mexico. A package of new and stronger interventions should be added to existing efforts such as food taxes and warning labels on non-nutritious food.

Toward healthy and sustainable diets for the 21st century: Importance of sociocultural and economic considerations.

Four years after the EAT-Lancet landmark report, worldwide movements call for action to reorient food systems to healthy diets that respect planetary boundaries. Since dietary habits are inherently local and personal, any shift toward healthy and sustainable diets going against this identity will have an uphill road. Therefore, research should address the tension between the local and global nature of the biophysical (health, environment) and social dimensions (culture, economy). Advancing the food system transformation to healthy, sustainable diets transcends the personal control of engaging consumers. The challenge for science is to scale-up, to become more interdisciplinary, and to engage with policymakers and food system actors. This will provide the evidential basis to shift from the current narrative of price, convenience, and taste to one of health, sustainability, and equity. The breaches of planetary boundaries and the environmental and health costs of the food system can no longer be considered externalities. However, conflicting interests and traditions frustrate effective changes in the human-made food system. Public and private stakeholders must embrace social inclusiveness and include the role and accountability of all food system actors from the microlevel to the macrolevel. To achieve this food transformation, a new "social contract," led by governments, is needed to redefine the economic and regulatory power balance between consumers and (inter)national food system actors.

Community coalition efforts to prevent childhood obesity: two-year results of the Shape Up Under 5 study.

BACKGROUND: Cross-sector collaborations and coalitions are promising approaches for childhood obesity prevention, yet there is little empirical evidence about how they affect change. We hypothesized that changes in knowledge of, and engagement with, childhood obesity prevention among coalition members can diffuse through social networks to influence policies, systems, and environments. METHODS: We studied a community coalition (N = 16, Shape Up Under 5 "SUU5 Committee") focused on early childhood obesity prevention in Somerville, MA from 2015-17. Knowledge, engagement, and social network data were collected from Committee members and their network contacts (n = 193) at five timepoints over two years. Policy, systems, and environment data were collected from the SUU5 Committee. Data were collected via the validated COMPACT Stakeholder-driven Community Diffusion survey and analyzed using regression models and social network analysis. RESULTS: Over 2 years, knowledge of (p = 0.0002), and engagement with (p = 0.03), childhood obesity prevention increased significantly among the SUU5 Committee. Knowledge increased among the Committee's social network (p = 0.001). Significant changes in policies, systems, and environments that support childhood obesity prevention were seen from baseline to 24 months (p = 0.003). CONCLUSION: SUU5 had positive effects on "upstream" drivers of early childhood obesity by increasing knowledge and engagement. These changes partially diffused through networks and may have changed "midstream" community policies, systems, and environments.

Using Agent-Based Modeling to Extrapolate Community-Wide Impact from a Stakeholder-Driven Childhood Obesity Prevention Intervention: Shape Up Under 5.

Objective: Whole-of-community interventions are a promising systems-based approach to childhood obesity prevention. A theorized driver of success is "Stakeholder-Driven Community Diffusion" (SDCD): the spread of knowledge about and engagement with obesity prevention efforts from a committee of stakeholder representatives. We focus on the potential of SDCD to affect the broader community. Methods: We use an agent-based model of SDCD to dynamically represent the interpersonal interactions that drive community diffusion of knowledge and engagement. We test its explanatory power using longitudinal data from a sample of community members and then use simulations to extrapolate from this limited sample to the unobserved community at large. We also consider counterfactual scenarios that show how changes in implementation strategy might have led to different patterns of community change. Results: Our model can reproduce real-world patterns of diffusion. Simulations show a substantial increase in knowledge (an approximate doubling) and a slight increase in engagement throughout the broader community. A relatively small amount of this change in knowledge (∼10%), and all the change in engagement is attributable to direct intervention effects on committee members. Conclusions: SDCD is premised on creating preconditions for sustainable change. Previous work has estimated impact on small samples closely linked to the stakeholder committee, but the degree to which this translates into the much broader diffusion envisioned by SDCD theory is unknown. This analysis demonstrates the potential of interventions to do just that. Additionally, the counterfactual scenarios suggest that simulation can help tailor implementation of SDCD interventions to increase impact.

Engaging with Brown Buttabean Motivation for Sustained Weight Loss.

Context Brown Buttabean Motivation (BBM) is a grassroot Pacific-led organisation aiming to reduce obesity amongst Pasifika (Pacific people in Aotearoa New Zealand) and Indigenous Maori, helping them choose a healthy and active life-style for themselves, their children and their wider family. BBM offers a holistic approach to weight loss, recognising that mental health, family and cultural factors all play essential and critical roles in nutrition and physical activity patterns. Objective To understand how participants experience and engage with BBM. Study Design &; Analysis Qualitative study conducted by our co-design research team within a broader BBM research project. Initial inductive thematic approach followed by theoretical deductive analysis of coded data guided by Pacific Fonofale and Maori Te Whare Tapa Wha health models. In this meeting-house metaphor, the floor is family, roof is culture, house-posts are physical, mental, spiritual and socio-demographic health and well-being, surrounded by environment, time and context. Setting South Auckland, New Zealand 2021 Population Studied BBM participants Instrument Semi-structured interviews Outcome Measures Narrative data Results 22 interviewees (50% female) aged 24-60 years of mixed Pacific and Maori ethnicities. Majority self-reported weight loss (between three and 135kg) since starting BBM. Two researchers independently coded data with adjudication (kappa=0.61) Participants identified the interactive holistic nature of health and wellbeing from BBM. As well as physical, mental and spiritual benefits, BBM helped many re-connect with both their family and their culture. BBM is seen as a new way of life. Participants "immediately belong to BBM family" regardless of culture or size, "with no judgements" and adopt the BBM motto "no excuses". Conclusions Many weight loss studies provide programmes to improve physical exercise and nutrition, but seldom address sustainability and other core factors such as mental health and motivation. BBM is a community-embedded Maori and Pasifika-led intervention, with no reliance on researchers nor external authorities for its ongoing implementation. It addresses factors impacting participants' lives and social determinants of health, including vaccination drives, food parcels and adapting to the COVID-19 pandemic and lockdowns. Our three-year longitudinal cohort study assessing sustained weight loss is ongoing.

Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND): protocol and baseline outcomes for a stepped-wedge cluster-randomised prevention trial.

INTRODUCTION: Systems science methodologies have been used in attempts to address the complex and dynamic causes of childhood obesity with varied results. This paper presents a protocol for the Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND) trial. RESPOND represents a significant advance on previous approaches by identifying and operationalising a clear systems methodology and building skills and knowledge in the design and implementation of this approach among community stakeholders. METHODS AND ANALYSIS: RESPOND is a 4-year cluster-randomised stepped-wedge trial in 10 local government areas in Victoria, Australia. The intervention comprises four stages: catalyse and set up, monitoring, community engagement and implementation. The trial will be evaluated for individuals, community settings and context, cost-effectiveness, and systems and implementation processes. Individual-level data including weight status, diet and activity behaviours will be collected every 2 years from school children in grades 2, 4 and 6 using an opt-out consent process. Community-level data will include knowledge and engagement, collaboration networks, economic costs and shifts in mental models aligned with systems training. Baseline prevalence data were collected between March and June 2019 among >3700 children from 91 primary schools. ETHICS AND DISSEMINATION: Ethics approval: Deakin University Human Research Ethics Committee (HREC 2018-381) or Deakin University's Faculty of Health Ethics Advisory Committee (HEAG-H_2019-1; HEAG-H 37_2019; HEAG-H 173_2018; HEAG-H 12_2019); Victorian Government Department of Education and Training (2019_003943); Catholic Archdiocese of Melbourne (Catholic Education Melbourne, 2019-0872) and Diocese of Sandhurst (24 May 2019). The results of RESPOND, including primary and secondary outcomes, and emerging studies developed throughout the intervention, will be published in the academic literature, presented at national and international conferences, community newsletters, newspapers, infographics and relevant social media. TRIAL REGISTRATION NUMBER: ACTRN12618001986268p.

Process evaluation of in-person, news and social media engagement of a community-based programme Brown Buttabean Motivation (BBM): a research protocol.

INTRODUCTION: The community group Brown Buttabean Motivation (BBM) initially began to assist Auckland Pasifika and Maori to manage weight problems, predominantly through community-based exercise sessions and social support. BBM's activities expanded over time to include many other components of healthy living in response to community need. With advent of the COVID-19 pandemic, BBM outreach grew to include a foodbank distributing an increasing amount of donated healthy food to families in need, a community kitchen and influenza and COVID-19 vaccine drives. A strong social media presence has served as the main means of communication with the BBM community as well as use of traditional news media (written, radio, television) to further engage with vulnerable members of the community. METHODS AND ANALYSIS: The study aims to conduct mixed method process evaluation of BBM's community engagement through in-person, social and news media outreach activities with respect to the health and well-being of Pasifika and Maori over time. The project is informed by theoretical constructs including Pacific Fa'afaletui and Fonofale and Maori Te Whare Tapa Wha Maori research frameworks and principles of Kaupapa Maori. It is further framed using the concept of community-driven diffusion of knowledge and engagement through social networks. Data sources include in-person community engagement databases, social and news media outreach data from archived documents and online resources. Empirical data will undergo longitudinal and time series statistical analyses. Qualitative text thematic analyses will be conducted using the software NVivo, Leximancer and AntConc. Image and video visual data will be randomly sampled from two social media platforms. The social media dataset contains almost 8000 visual artefacts. ETHICS AND DISSEMINATION: Ethics approval obtained from University of Auckland Human Participants Ethics Committee UAHPEC 23456. Findings will be published in peer-reviewed publications, disseminated through community meetings and conferences and via BBM social network platforms. TRIAL REGISTRATION NUMBER: ACTRN 12621 00093 1875.

Systems Mapping of the New Zealand Free and Healthy School Lunch Programme: Perspectives from Lunch Providers.

As part of the COVID-19 economic recovery package, the Aotearoa New Zealand Government rolled out a universal free and healthy lunch programme to the 25% least advantaged schools nationwide. This study explored experiences of school lunch providers in the Hawke's Bay region. The aim was to create a systems map identifying points of intervention through which the lunch programme could be improved to meet the goal of reducing child food insecurity. Twelve lunch providers were interviewed to generate casual loop diagrams which were examined and integrated to form a single systems map. Seven themes arose during analysis: teacher support, principal support, nutrition guidelines and government support, supply chain, ingredient suppliers, student feedback and food waste. Teacher support was important for getting students to try new foods and eat the nutritious lunches. Principal support was a strong theme impacting opportunities for broader student engagement. This study employed systems science to highlight the importance of support from different stakeholders within the lunch programme to achieve the goal of reduced child food insecurity. Further work is needed to ensure the programme meets the wider goals of the government and community, and to determine the potential broader benefits of the programme.