Dr James Nobles

Background Weight management services have not always benefitted everyone equally. People who live in more deprived areas, racially minoritised communities, those with complex additional needs (e.g., a physical or mental disability), and men are less likely to take part in weight management services. This can subsequently widen health inequalities. One way to counter this is to co-design services with under-served groups to better meet their needs. Using a case study approach, we explored how co-designed adult weight management services were developed, the barriers and facilitators to co-design, and the implications for future commissioning. Methods We selected four case studies of adult weight management services in Southwest England where co-design had been planned, representing a range of populations and settings. In each case, we recruited commissioners and providers of the services, and where possible, community members involved in co-design activities. Interviews were conducted online, audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results We interviewed 18 participants (8 female; 10 male): seven commissioners, eight providers, and three community members involved in co-designing the services. The case studies used a range of co-design activities (planned and actualised), from light-touch to more in-depth approaches. In two case studies, co-design activities were planned but were not fully implemented due to organisational time or funding constraints. Co-design was viewed positively by participants as a way of creating more appropriate services and better engagement, thus potentially leading to reduced inequalities. Building relationships– with communities, individual community members, and with partner organisations– was critical for successful co-design and took time and effort. Short-term and unpredictable funding often hindered co-design efforts and could damage relationships with communities. Some commissioners raised concerns over the limited evidence for co-design, while others described having to embrace “a different way of thinking” when commissioning for co-design. Conclusions Co-design is an increasingly popular approach to designing health in services but can be difficult to achieve within traditional funding and commissioning practices. Drawing on our case studies, we present key considerations for those wanting to co-design health services, noting the importance of building strong relationships, creating supportive organisational cultures, and developing the evidence base.

Background and Objective: Interventions are needed to prevent and mitigate unhealthy commodity industry (UCI) influence on policy, which poses a significant barrier to advancing effective policy. Whilst literature on interventions to address such influence is beginning to emerge, current conceptualisations may be incomplete as they fail to consider the wider systemic complexities surrounding UCI influence, such as industry adaptivity or its enabling factors. This study aims to apply a systems thinking lens to explore possible interventions that could help address UCs influence on policy. methodsA series of workshops were conducted between November 2021 and February 2022 with stakeholders from academia, industry monitoring groups, civil society, government, and intergovernmental organisations with expertise in UCIs. Stakeholders identified and discussed possible interventions to effectively address UCI influence on policy. Workshop data were coded and analysed using NVivo. Results: A total of fifty-two stakeholders participated in twenty-three online workshops. Preliminary results collated 43 groups of interventions that aim to decrease: direct access to public sector decisionmakers; confusion and doubt about policy decisions; industry’s ability to prioritise their growth and profits; industry’s ability to leverage legal and dispute settlement processes; and industry’s ability to leverage policymaking, norms, rules, and laws in their favour. In addition, stakeholders suggested leadership, and coordination and cooperation between stakeholders as key actions to achieve interventions. Conclusions: Workshops identified a disparate and heterogenous range of interventions. The complexities surrounding UCIs influence suggest that interventions need to: work in concurrently in different parts of the system; apply to broad policymaking processes, not just particular industries; strengthen intermediary actions to achieve change; and target system structures, such as sources of corporate power beyond policymaking processes, which may be overlooked without a systems lens. Government, public health, and civil society actors could consider investing time and resources to support or advance these interventions.

Background: Interventions are needed to prevent and mitigate unhealthy commodity industry (UCI) influence on public health policy. Whilst literature on interventions is emerging, current conceptualisations remain incomplete as they lack considerations of the wider systemic complexities surrounding UCI influence, which may limit intervention effectiveness. This study applies systems thinking as a theoretical lens to help identify and explore how possible interventions relate to one another in the systems in which they are embedded. Related challenges to addressing UCI influence on policy, and actions to support interventions, were also explored. Methods: Online participatory workshops were conducted with stakeholders with expertise in UCIs. A systems map, depicting five pathways to UCI influence, and the Action Scales Model were used to help participants identify interventions and guide discussions. Codebook thematic analysis was used to analyse the data. Results: Fifty-two stakeholders participated in 23 workshops. Participants identified 27 diverse, interconnected and interdependent interventions corresponding to the systems map’s pathways that reduce the ability of UCIs to influence policy, e.g., reform policy financing; regulate public-private partnerships; reform science governance and funding; frame and reframe the narrative, challenge neoliberalism and GDP growth; leverage human rights; change practices on multistakeholder governance; and reform policy consultation and deliberation processes. Participants also identified four potential key challenges to interventions (i.e., difficult to implement or achieve; partially formulated; exploited or misused; requires tailoring for context), and four key actions to help support intervention delivery (i.e., coordinate and cooperate with stakeholders; invest in civil society; create a social movement; nurture leadership). Conclusion: A systems thinking lens revealed the theoretical interdependence between disparate and heterogenous interventions. This suggests that to be effective, interventions need to align, work collectively, and be applied to different parts of the system synchronously. Importantly, these interventions need to be supported by intermediary actions to be achieved. Urgent action is now required to strengthen healthy alliances and implement interventions.

Background: Unhealthy commodity industries (UCIs) engage in political practices to influence public health policy, which poses barriers to protecting and promoting public health. Such influence exhibits characteristics of a complex system. Systems thinking would therefore appear to be a useful lens through which to study this phenomenon, potentially deepening our understanding of how UCI influence are interconnected with one another through their underlying political, economic and social structures. As such this study developed a qualitative systems map to depict the complex pathways through which UCIs influence public health policy and how they are interconnected with underlying structures. Methods: Online participatory systems mapping workshops were conducted between November 2021 and February 2022. As a starting point for the workshops, a preliminary systems map was developed based on recent research. Twenty-three online workshops were conducted with 52 geographically diverse stakeholders representing academia, civil society, public office and global governance organisations. Analysis of workshop data in NVivo and feedback from participants resulted in a final systems map. Results: The preliminary systems map consisted of 40 elements across six interdependent themes. The final systems map consisted of 64 elements across five interdependent themes, representing key pathways through which UCIs impact health policymaking: 1) direct access to public sector decision-makers; 2) creation of confusion and doubt about policy decisions; 3) corporate prioritisation of commercial profits and growth; 4) industry leveraging the legal and dispute settlement processes; and 5) industry leveraging policymaking, norms, rules, and processes. Conclusion: UCI influence on public health policy is highly complex, involves interlinked practices, and is not reducible to a single point within the system. Instead, pathways to UCI influence emerge from the complex interactions between disparate national and global political, economic and social structures. These pathways provide numerous avenues for UCIs to influence public health policy, which poses challenges to formulating a singular intervention or limited set of interventions capable of effectively countering such influence. Using participatory methods, we made transparent the interconnections that could help identify interventions future work.

In March 2014, the consultation document Joined up Clinical Pathways for Obesity was published, exploring options for the future commissioning responsibilities of Tier 3 and 4 weight management services. What became apparent was the lack of reference to childhood weight management services (more so at Tier 3), which mirrors the scarcity of evidence-based research in this area. This article asks a number of key questions: who should provide Tier 3 services for children and young people (CYP), what does such a service look like and who should fund these services for CYP? Greater commitment is needed from the Department of Health to provide clarity for Tier 3 service providers. SHINE (Self-Help, Independence, Nutrition and Exercise), an established Tier 3 service for CYP with severe obesity, is an example of what a Tier 3 programme can look like. Finally, it is proposed that funding is better distributed across the Obesity Care Pathway to ensure that CYP with severe obesity can access appropriate treatment.

Weight management is a game of chance for most children and young people, and is dependent on service availability and the expertise of the provider. Many localities are without established weight-management services, and the effectiveness of those provided is often not well-known. SHINE (Self Help, Independence, Nutrition and Exercise) is the only documented tier 3 community-based service provider in the UK. It offers a plethora of interventions tailored to each child or young person using a stepped-care approach (SCA) to treat severe obesity: as the severity of obesity increases, so does the intensity of intervention. This article describes an SCA and uses this model to demonstrate a range of appropriate, available interventions. A SCA can provide a holistic and integrative care pathway for children and young people with severe obesity when implemented at tier 3.

Background Exposure to advertising of unhealthy commodities such as fast-food and gambling is recognised as a risk factor for developing non-communicable diseases. Assessment of the impact of such advertisement and the evaluation of the impact of any policies to restrict such advertisements on public health are reliant on the quality of the exposure assessment. A straightforward method for assessing exposure is to ask people whether they noticed any such advertisements in their neighbourhoods. However, the validity of this method is unclear. We assessed the associations between measured exposure to outdoor advertising, self-reported exposure, and self-reported consumption. Methods We collected exposure information in January-March 2022 using two methods: (i) through a resident survey investigating advertising and consumption of unhealthy products, distributed across Bristol and neighbouring South Gloucestershire, and (ii) through in-person auditing. Self-reported exposure was obtained from the resident survey (N = 2,560) and measured exposure from photos obtained for all Council owned advertisement sites (N = 973 bus stops). Both data sources were geographically linked at lower-super-output-area level. Reporting ratios (RRs), 95% confidence intervals (CIs), and Cohen’s kappas, are presented. Results 24% of advertisements displayed food and/or drink advertising. Bristol respondents in neighbourhoods displaying food/drink adverts were more likely to also report seeing these adverts compared to those in neighbourhoods without food/drink adverts (59% vs. 51%, RR = 1.15, 95%CI 1.01–1.31). There was no such association in South Gloucestershire (26% vs. 32%, RR = 0.82, 95%CI 0.58–1.14). Respondents in both Bristol and South Gloucestershire who recalled seeing advertising for unhealthy food and drink products were more likely to consume them (e.g. for fast-food: 22% vs. 11%, RR = 2.01, 95%CI 1.68–2.42). There was no such association between measured food and drink adverts in respondents’ local areas and self-reported consumption of HFSS product (90.1% vs. 90.7%, RR = 0.99, 95%CI 0.96–1.03). Conclusions Self-reported outdoor advertisement exposure is correlated with measured exposure, making this a useful methodology for population studies. It has the added advantage that it correlates with consumption. However, given that measurement error can be significant and self-reported exposure is known to be susceptible to various biases, inferences from studies using this exposure metric should be made with caution.

Introduction: Engagement denotes the extent to which, and how, individuals and families participate in a weight management (WM) programme. Data suggest that between 8-83% of families do not complete the paediatric WM programme which they initiated, but the underlying mechanisms which drive participant engagement are poorly understood. This thesis aims to 1) establish if participant-and programme-characteristics are associated with various engagement trajectories in paediatric WM programmes, and 2) explain the factors associated with initial-and continued-programme engagement. The Model of Retention – translated from Higher Education – underpins this thesis.  Study 1: Methods – Secondary data of 2948 MoreLife participants (age: 10.44±2.80 years, BMI SDS: 2.48±0.87 units, white ethnicity: 70.52 %) were used. Multivariable linear regression and multivariable logistic regression examined the predictors of attendance and engagement groups (e.g. early dropout, late dropout, completion…) respectively. Results – Six variables were associated with engagement (Programme: group size, delivery period, & programme year; Participant: BMI SDS, Ethnicity, & IMD score). Programme characteristics were stronger predictors of engagement than participant characteristics, and the predictors varied between engagement groups. A small proportion of the variance in engagement was explained by the final predictors.  Study 2: Methods – Qualitative data were collected from 31 families (parents and children) across three paediatric WM programmes (MoreLife, SHINE, and Weigh To Go) at the early-and late-programme stages. The Model of Retention guided the lines of inquiry and data analysis framework. Results – Six factors were central to engagement: 1) having support; 2) self-efficacy in one’s ability to attend; 3) coping with the demands of programme engagement; 4) controlling engagement decisions; 5) experiencing benefits from engagement; and, 6) having an engagement promoting programme design. The importance and dominance of these factors varied between the early-and lateprogramme stages, and moreover, between parents and children.  Conclusions: Participant engagement was demonstrated to be a complex phenomenon; one that is challenging to predict and currently better explained through qualitative investigation. This thesis, and the collective discussion within, illuminate methods of improving WM programme engagement through design and delivery modification. The Model of Retention offers a means of comprehensively explaining engagement. Finally, this thesis provides a conceptual framework for discussing programme engagement.

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. The overall aim of the review is to determine the effectiveness of interventions to prevent obesity in 12 to 18-year-old children and adolescents. The four objectives are:. to evaluate the effects of interventions that aim to modify dietary intake on changes in zBMI score, BMI and serious adverse events among children and adolescents; to evaluate the effects of interventions that aim to modify physical activity, sedentary behaviour, sleep, play and/or structured exercise on changes in zBMI score, BMI and serious adverse events among children and adolescents; to evaluate the combined effects of interventions that aim to modify both dietary intake and physical activity/movement behaviours on changes in zBMI score, BMI and serious adverse events among children and adolescents; to compare the effects of interventions that aim to modify dietary interventions with those that aim to modify physical activity/movement behaviours on changes in zBMI score, BMI and serious adverse events among children. The secondary objectives are designed to explore if, how, and why the effectiveness of interventions on zBMI/BMI varies depending on the following PROGRESS factors. Place of residence Race/ethnicity/culture/language Occupation Gender/sex Religion Education Socioeconomic status Social capital. The PROGRESS acronym is intended to ensure that there is explicit consideration of health inequity, the unfair difference in disease burden, when conducting research and adapting research evidence to inform the design of new interventions (O'Neill 2014). The PROGRESS acronym describes factors that contribute to health inequity. Recent work on race and religion in the UK suggested that consideration of these factors is critical to the design of new interventions (Rai 2019). We will also collect, from RCTs, information about the costs of interventions so that policymakers can use the review as a source of information from which they may prepare cost-effectiveness analyses.

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. The overall aim of the review is to determine the effectiveness of interventions to prevent obesity in 5 to 11-year-old children. The four objectives are:. to evaluate the effects of interventions that aim to modify dietary intake on changes in zBMI score, BMI and serious adverse events among children; to evaluate the effects of interventions that aim to modify physical activity, sedentary behaviour, sleep, play and/or structured exercise on changes in zBMI score, BMI and serious adverse events among children; to evaluate the combined effects of interventions that aim to modify both dietary intake and physical activity/movement behaviours on changes in zBMI score, BMI and serious adverse events among children; to compare the effects of interventions that aim to modify dietary interventions with those that aim to modify physical activity/movement behaviours on changes in zBMI score, BMI and serious adverse events among children. The secondary objectives are designed to explore if, how, and why the effectiveness of interventions on zBMI/BMI varies depending on the following PROGRESS factors. Place of residence Race/ethnicity/culture/language Occupation Gender/sex Religion Education Socioeconomic status Social capital. The PROGRESS acronym is intended to ensure that there is explicit consideration of health inequity, the unfair difference in disease burden, when conducting research and adapting research evidence to inform the design of new interventions (O'Neill 2014). The PROGRESS acronym describes factors that contribute to health inequity. Recent work on race and religion in the UK suggests that consideration of these factors is critical to the design of new interventions (Rai 2019). We will also collect, from RCTs, information about the costs of interventions so that policymakers can use the review as a source of information from which they may prepare cost-effectiveness analyses.

OBJECTIVE: To conduct a systematic review of the literature for strategies designed to reduce attrition in managing paediatric obesity. METHODS: We searched Ovid Medline (1946 to May 6, 2020), Ovid Embase (1974 to May 6, 2020), EBSCO CINAHL (inception to May 6, 2020), Elsevier Scopus (inception to April 14, 2020), and ProQuest Dissertations & Theses (inception to April 14, 2020). Reports were eligible if they included any obesity management intervention, included 2 to 18 year olds with overweight or obesity (or if the mean age of participants fell within this age range), were in English, included experimental study designs, and had attrition reduction as a main outcome. Two team members screened studies, abstracted data, and appraised study quality. RESULTS: Our search yielded 5,415 original reports; six met inclusion criteria. In three studies, orientation sessions (n = 2) and motivational interviewing (MI) (n = 1) were used as attrition-reduction strategies before treatment enrollment; in three others, text messaging (n = 2) and MI (n = 1) supplemented existing obesity management interventions. Attrition-reduction strategies led to decreased attrition in two studies, increased in one, and no difference in three. For the two strategies that reduced attrition, (a) pre-treatment orientation and (b) text messaging between children and intervention providers were beneficial. The quality of the six included studies varied (good [n = 4]; poor [n = 2]). CONCLUSION: Some evidence suggests that attrition can be reduced. The heterogeneity of approaches applied and small number of studies included highlight the need for well-designed, experimental research to test the efficacy and effectiveness of strategies to reduce attrition in managing paediatric obesity.

Effective physical activity messaging plays an important role in the pathway towards changing physical activity behaviour at a population level. The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC) are outputs from a recent modified Delphi study. This sought consensus from an international expert panel on how to aid the creation and evaluation of physical activity messages. In this paper, we (1) present an overview of the various concepts within the PAMF and PAMC, (2) discuss in detail how the PAMF and PAMC can be used to create physical activity messages, plan evaluation of messages, and aid understanding and categorisation of existing messages, and (3) highlight areas for future development and research. If adopted, we propose that the PAMF and PAMC could improve physical activity messaging practice by encouraging evidence-based and target population-focused messages with clearly stated aims and consideration of potential working pathways. They could also enhance the physical activity messaging research base by harmonising key messaging terminologies, improving quality of reporting, and aiding collation and synthesis of the evidence.

Engagement denotes the extent to which, and how, individuals participate in weight management (WM) services. Effective WM services should generate meaningful outcomes and promote high participant engagement; however, research is predominantly focused on the former. Given that engagement is a poorly understood phenomenon, and that engagement-related concepts are often used synonymously (e.g., dropout and attrition), the engagement pathway is hereby introduced. This pathway defines key concepts (e.g., recruitment, adherence, attrition) and their relationships in the enrolment, intervention, and maintenance stages of treatment. The pathway will help researchers and practitioners better understand engagement-related concepts whilst encouraging greater conceptual consistency between studies.

We read with interest the recently published clinical practice guidelines for preventing and treating childhood obesity (1). The authors reported their evaluation of the quality of the evidence and an assessment of the strength of recommendations according to objective criteria across a diverse literature. In our view, however, this excellent and comprehensive report does not mention two relevant issues: attrition and enrollment. These issues are likely to be of concern for clinicians, administrators, and researchers because they can have a substantial impact on clinical care.

Abstract

Background Disciplinary behaviour management strategies are implemented in schools to help manage pupil behaviour. There is limited evidence of their intended impact on behaviour and academic outcomes for pupils but a growing concern for the potential negative impact that punitive approaches may have on pupil wellbeing. Methods We carried out a systematic review of the impact of disciplinary behaviour management strategies in schools on pupil psychosocial outcomes. We searched multiple electronic databases, and other sources. Primary outcomes were mental health and wellbeing, and secondary outcomes were social behaviours and academic attainment. Double screening of all titles, abstracts and full texts was undertaken, and data extraction was led by one reviewer with second reviewer checking all. Risk of bias was assessed using Cochrane Effective Practice and Organisation of Care (EPOC) group’s criteria for nonrandomised studies. Results were narratively synthesised. Results We included 14 studies from 5375 citations, assessing three types of strategies: temporary suspension (n = 10), verbal reprimand (n = 2), and mixed strategies (suspension along with other disciplinary intervention; n = 2), reporting on 18 primary and secondary outcomes. Depression was the most frequently reported outcome (n = 7), followed by academic grade scores (n = 4) and poor social behaviour in class (n = 4). Studies were mostly surveys, and all except one were at high risk of bias. We found a recurring pattern in the evidence of disciplinary strategies associated with poor mental health and social behaviour in pupils. The effect on academic attainment was unclear. Conclusions Disciplinary strategies aimed at improving behaviour at school may have negative effects on the pupil mental wellbeing as well as class behaviour. These are important consequences and should be assessed in better designed studies before these strategies are implemented.

Abstract

Background: Evaluation approaches such as ripple effects mapping (REM) and realist evaluation have emerged as popular methodologies to evidence impact, and the processes of change within public health as part of whole systems approaches. Despite the various examples of their implementation across different evaluation settings, there has been little or no evidence of how they might be effective when combined. Methods: With REM’s potential to pragmatically illustrate impact, and realist evaluation’s strength to identify how and why impacts emerge, this paper develops a rationale and process for their amalgamation. Following this, we outline a realist-informed ripple effects mapping (RREM) protocol that may be suitable for application within evaluation settings in a range of public health, whole system and physical activity settings. Discussion: Combining these two approaches has the potential to more effectively illuminate the impacts that we see within public health and whole system approaches and initiatives. What is more, given the complexity often imbued within these approaches and initiatives they hold capability for also capturing the causal mechanisms that explain these impacts. Conclusions: It is our conclusion that when combined, this novel approach may help to inspire future research as well as more effective evaluation of public health and whole system approaches. This is crucial if we are to foster a culture for learning, refinement and reflection.

Background Disciplinary behaviour management strategies are implemented in schools to manage pupil behaviour. There is limited evidence of their intended impact on behaviour but there is growing concern around the potential negative impacts on pupil wellbeing. Methods We carried out a systematic review to examine the impact of these strategies on psychosocial outcomes in pupils (PROSPERO Registration: CRD42021285427). We searched multiple sources and double-screened titles, abstracts, and full texts. Data extraction and risk of bias assessment were done by one reviewer and checked by another. Results were narratively synthesised. Results We included 14 studies, from 5375 citations, assessing temporary suspension (n=10), verbal reprimand (n=2), and mixed strategies (n=2). Depression was the most common outcome (n=7), followed by academic grades (n=4) and behaviour in class (n=4). All except one study were at high risk of bias. We found a recurring pattern in the evidence of disciplinary strategies associated with poor mental wellbeing and behaviour in pupils. The effect on academic attainment was unclear. Conclusions Disciplinary behaviour management strategies may have negative impact on pupil mental wellbeing and class behaviour. These important consequences should be assessed in better designed studies before these strategies are implemented.

Background Evaluation approaches such as ripple effects mapping (REM) and realist evaluation have emerged as popular methodologies to evidence impact, and the processes of change within public health as part of whole systems approaches. Despite the various examples of their implementation across different evaluation settings, there has been little or no evidence of how they might be effective when combined. Methods With REM’s potential to pragmatically illustrate impact, and realist evaluation’s strength to identify how and why impacts emerge, this paper develops a rationale and process for their amalgamation. Following this, we outline a realist-informed ripple effects mapping (RREM) protocol drawing upon a physical activity based case study in Essex that may be suitable for application within evaluation settings in a range of public health, whole system and physical activity settings. Discussion Combining these two approaches has the potential to more effectively illuminate the impacts that we see within public health and whole system approaches and initiatives. What is more, given the complexity often imbued within these approaches and initiatives, they hold capability for also capturing the causal mechanisms that explain these impacts. Conclusions It is our conclusion that when combined, this novel approach may help to inspire future research as well as more effective evaluation of public health and whole system approaches. This is crucial if we are to foster a culture for learning, refinement and reflection.

Ripple effects mapping is a qualitative and participatory method, developed to capture the dynamic nature and interacting elements of an initiative, and its impacts. We present our experiences of using ripple effects mapping to evaluate complex public health initiatives across seven case studies in Bradford, UK. Seven researchers engaged in qualitative reflective practice to capture their individual experiences of using ripple effects mapping within their research and practice; outlining how the method has been adapted and highlighting key reflections and recommendations for implementing ripple effects mapping in the future. We developed ten recommendations, with corresponding strategies, for implementing ripple effects mapping sessions. The recommendations outline how ripple effects mapping can be implemented to improve engagement and anticipate and overcome potential barriers. In doing so, we outline how ripple effects mapping can be used, and adapted, to evaluate various public health initiatives, in research and practice.

Complexity science is an interdisciplinary paradigm that helps people understand how outcomes, such as domestic violence and abuse (DVA), arise from within complex adaptive systems. This study aims to identify how complexity science has been applied in DVA literature. A systematic scoping review was conducted, searching across academic databases and Google for articles. Articles published from 1990 to 2020, written in English, had DVA partner abuse as a focus, and used complexity science as a focus or theoretical background to the paper, were considered for inclusion. Data was extracted and narratively synthesized in an iterative manner. Twenty-one studies were included, originating predominantly from the United States and New Zealand, and published mainly after 2009. Approximately 70% of authorships were comprised of interdisciplinary teams. Most papers strongly incorporated complexity science as a methodological approach and applied methods, such as systems modeling (agent-based modeling or systems dynamics modeling), aligning with computer science or engineering disciplines. Some used complexity theory combined with qualitative techniques (interviews or discourse analysis) strongly associated with social sciences research. Methods and findings were heterogeneous and often explored interactions between parts of the system and the subsequent phenomena that emerged from these interactions. Complexity science can: (a) support a holistic understanding of DVA; (b) combine different perspectives; (c) encourage interdisciplinary teams to work collaboratively around an issue such as DVA; (d) identify leverage points to assist in targeting scarce resources; (e) help predict emergent phenomena and unexpected consequences of policy change.

Abstract

Background: Weight management services have not always benefitted everyone equally. People who live in more deprived areas, racially minoritised communities, those with complex additional needs (e.g. a physical or mental disability), and men are less likely to take part in weight management services. This can subsequently widen health inequalities. One way to counter this is to co-design services with under-served groups to better meet their needs. Using a case study approach, we explored how co-designed adult weight management services were developed, the barriers and facilitators to co-design, and the implications for future commissioning. Methods: We selected four case studies of adult weight management services in Southwest England in which co-design had been planned, representing a range of populations and settings. In each case, we recruited commissioners and providers of the services, and where possible, community members involved in the co-design activities. Interviews were conducted online, audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results: We interviewed 18 participants (8 female; 10 male): seven commissioners, eight providers, and three community members involved in co-designing the services. The case studies used a range of co-design activities (planned and actualised), from light-touch to more in-depth approaches. In two case studies, co-design activities were planned but were not fully implemented due to organisational time or funding constraints. Co-design was viewed positively by participants as a way of creating more appropriate services and better engagement, thus potentially leading to reduced inequalities. Building relationships – with communities and with partner organisations – was critical for successful co-design and took time and effort. Short-term and unpredictable funding often hindered co-design efforts and could result in damaged relationships with communities. Some commissioners raised concerns over the limited evidence base for co-design, while others described having to embrace “a different way of thinking” when commissioning for co-design. Conclusions: Co-design is an increasingly popular approach to designing health in services but can be difficult to achieve within traditional funding and commissioning practices. Drawing on our case studies, we present key considerations for those wanting to co-design health services, noting the importance of building strong relationships, creating supportive organisational cultures, and developing the evidence base.

Abstract

Background Bristol City Council introduced a new advertisement policy in 2021/2022 which included prohibiting the advertising of unhealthy food and drink (HFSS), alcohol, gambling and payday loans across council-owned advertising spaces. This mixed methods study is part of the BEAR study, and aimed to explore the rationale and the barriers and facilitators to implementing the policy, and describe the perceived advertising environment prior to implementation. Methods Semi-structured interviews were carried out with seven stakeholders involved in the design and implementation of the advertising policy. A stakeholder topic guide was developed before interviews took place to help standardise the lines of inquiry between interviewees. A resident survey was developed to collect socio-demographic data and, for the purpose of this study, information regarding observations of advertising for HFSS products, alcohol and gambling. Results Fifty-eight percent of respondents residing in Bristol and South Gloucestershire reported seeing advertisements for unhealthy commodities in the week prior to completing the survey. This was highest for HFSS products (40%). 16% of residents reported seeing HFSS product advertisements specifically appealing to children. For HFSS products in particular, younger people were more likely to report seeing adverts than older people, as were those who were from more deprived areas. An advertisement policy that restricts the advertisement of such unhealthy commodities, and in particular for HFSS products, has the potential to reduce health inequalities. This rationale directly influenced the development of the advertisement policy in Bristol. Implementation of the policy benefitted from an existing supportive environment following the ‘health in all policies’ initiative and a focus on reducing health inequalities across the city. Conclusions Unhealthy product advertisements, particularly for unhealthy food and drinks, were observed more by younger people and those living in more deprived areas. Policies that specifically restrict such advertisements, therefore, have the potential to reduce health inequalities, as was the hope when this policy was developed. Future evaluation of the policy will provide evidence of any public health impact.

Stories can be a powerful method of exploring complexity, and the factors affecting everyday physical activity within a modern urban setting are nothing if not complex. The first part of our How Do You Move? study focused on the communication of physical activity guidelines to under-served communities. A key finding was that adults especially wanted physical activity messages to come from ‘everyday people, people like us’. This finding also reflects a wider move to use more relatable imagery in health promotion campaigns. Using a portrait vignette approach to create monologues, we set out to explore the experiences of people from diverse backgrounds living in Bristol, all of whom took part in varied leisure time physical activities but would also be considered to lead ‘normal’ lives. We aim to demonstrate that stories of such ‘experts by experience’ can contribute to how physical activity is perceived and elucidate the complex interplay of barriers and enablers in everyday experiences of physical activity.

BACKGROUND: The International Society for Physical Activity and Health (ISPAH) is a leading global organization working to advance research, policy, and practice to promote physical activity. Given the expanding evidence base on interventions to promote physical activity, it was timely to review and update a major ISPAH advocacy document-Investments that Work for Physical Activity (2011). METHODS: Eight investment areas were agreed upon through consensus. Literature reviews were conducted to identify key evidence relevant to policymakers in each sector or setting. RESULTS: The 8 investment areas were as follows: whole-of-school programs; active transport; active urban design; health care; public education; sport and recreation; workplaces; and community-wide programs. Evidence suggests that the largest population health benefit will be achieved by combining these investments and implementing a systems-based approach. CONCLUSIONS: Establishing consensus on 'what works' to change physical activity behavior is a cornerstone of successful advocacy, as is having appropriate resources to communicate key messages to a wide range of stakeholders. ISPAH has created a range of resources related to the new investments described in this paper. These resources are available in the 'advocacy toolkit' on the ISPAH website (www.ispah.org/resources).

Despite many countries having physical activity guidelines, there have been few concerted efforts to mobilize this information to the public. The aim of this study was to understand the preferences of under-served community groups about how the benefits of physical activity, and associated guidelines, can be better communicated to the public. Participatory workshops, co-developed between researchers, a local charity, and a community artist, were used to gather data from four groups in Bristol, UK: young people (n = 17); adults (n = 11); older adults (n = 5); and Somali women (n = 15). Workshop content was structured around the study aims. The community artist and/or the local charity delivered the workshops, with researchers gathering data via observation, photos, and audio-recordings, which were analysed using the framework method. All four groups noted that the benefits of physical activity should be included within any communications efforts, though not restricted to health-related benefits. Language used should be simple and jargon-free; terms such as "sedentary", "vigorous" and "intensity" were deemed inaccessible, however all groups liked the message "some is good, more is better". Views about preferred mechanisms, and messenger, for delivering physical activity messages varied both between, and within, groups. Recommendations for those working in physical activity communications, research, and policy are provided.

OBJECTIVES: Systems approaches aim to change the environments in which people live, through cross-sectoral working, by harnessing the complexity of the problem. This paper sought to identify: (1) the strategies which support the implementation of We Can Move (WCM), (2) the barriers to implementation, (3) key contextual factors that influence implementation and (4) impacts associated with WCM. DESIGN: A multi-methods evaluation of WCM was completed between April 2019 and April 2021. Ripple Effects Mapping (REM) and semi-structured interviewers were used. Framework and content analysis were systematically applied to the dataset. SETTING: WCM-a physical activity orientated systems approach being implemented in Gloucestershire, England. PARTICIPANTS: 31 stakeholder interviews and 25 stakeholders involved in 15 REM workshops. RESULTS: A white-water rafting analogy was developed to present the main findings. The successful implementation of WCM required a facilitative, well-connected and knowledgeable guide (ie, the lead organisation), a crew (ie, wider stakeholders) who's vision and agenda aligned with WCM's purpose, and a flexible delivery approach that could respond to ever-changing nature of the river (ie, local and national circumstances). The context surrounding WCM further strengthened and hampered its implementation. Barriers included evaluative difficulties, a difference in stakeholder and organisational perspectives, misaligned expectations and understandings of WCM, and COVID-19 implications (COVID-19 also presented as a facilitative factor). WCM was said to strengthen cohesion and collaboration between partners, benefit other agendas and policies (eg, mental health, town planning, inequality), and improve physical activity opportunities and environments. CONCLUSIONS: This paper is one of the first to evaluate a systems approach to increasing physical activity. We highlight key strategies and contextual factors that influenced the implementation of WCM and demonstrate some of the wider benefits from such approaches. Further research and methodologies are required to build the evidence base surrounding systems approaches in Public Health.

Childhood obesity is a global public health concern. While evidence from a recent comprehensive Cochrane review indicates school-based interventions can prevent obesity, we still do not know how or for whom these work best. We aimed to identify the contextual and mechanistic factors associated with obesity prevention interventions implementable in primary schools. A realist synthesis following the Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES) guidance was with eligible studies from the 2019 Cochrane review on interventions in primary schools. The initial programme theory was developed through expert consensus and stakeholder input and refined with data from included studies to produce a final programme theory including all of the context-mechanism-outcome configurations. We included 24 studies (71 documents) in our synthesis. We found that baseline standardised body mass index (BMIz) affects intervention mechanisms variably as a contextual factor. Girls, older children and those with higher parental education consistently benefitted more from school-based interventions. The key mechanisms associated with beneficial effect were sufficient intervention dose, environmental modification and the intervention components working together as a whole. Education alone was not associated with favourable outcomes. Future interventions should go beyond education and incorporate a sufficient dose to trigger change in BMIz. Contextual factors deserve consideration when commissioning interventions to avoid widening health inequalities.

The reduced physical activity of women when they become mothers is a public health priority. Existing studies show that mothers have little time for leisure, or time that is fragmented and requiring negotiation with others. However, the temporal features of mothering are undertheorised and qualitative studies tend to focus on how mothers can skilfully construct physically active identities and balance societal expectations about being a "good mother". In line with other research that focuses on the configuration of everyday practices that condition the "possibilities" for health-related practices like physical activity, we shift our focus away from the resisting capacities of mothers to the temporal features of mothering practices. We interrogate the lived experiences of 15 mothers of preschool children in deprived urban areas and illuminate the inherent temporal dimensions, demands and dispositions of mothering practices that condition the possibility of leisure time physical activity being undertaken. Together, these temporal features mean mothering practices can readily work against leisure time physical activity. The focus on the mothering practices rather than mothers brings a novel perspective for developing public health policy designed to support mothers into regular leisure time physical activity.

Background Approaches from systems science are increasingly being trialed in public health because the drivers of poor health are complex, unpredictable and difficult to disentangle. While a broad range of methods is available to study systems science, one method alone is often insufficient for evaluation, as each offer only a limited perspective. Yet, few examples exist showing how several methods can be pragmatically integrated to generate new and meaningful insights, which is vital within systems changes. This paper describes, exemplifies and discusses the Integrated Methods for Public Health action Tracking (IMPAcT) process, which integrates group model building, Causal Loop Diagramming (CLD), the Action Scales Model (ASM), an Action Registry (AR) and Ripple Effects Mapping (REM), to better understand and address complexity within public health interventions. Methods We used common approaches for understanding system organization and interconnections (e.g. through CLD), identifying places to intervene in the system (e.g. ASM), tracking actions implemented within the system (e.g. REM) and understanding the impact at individual level of actions. We illustrate how the IMPAcT process can be applied via a case from a Danish project, the Healthy Active Children Study. Results We present a development process, that combines the above-mentioned approaches, to capture the behaviour, and allow tracking and evaluation of a system following several intervention efforts. Integrating complementary, participatory methods enabled a formative evaluation process that supported continuous learning, adaptation and improvement across complex systems. In the IMPAcT process, methods served both as evaluation tools and as means of stakeholder engagement and knowledge co-production. Embedding reflection and dialogue allowed stakeholders to examine practice and shape next steps. Visuals and narratives enhanced the clarity and impact of the evaluation. Conclusions The new process supports both those working at the front-line of systems change efforts, but also researchers, municipality staff and none the least, policymakers.

Background Recent systematic reviews and meta-analyses on the effects of interventions to prevent obesity in children aged 5–18 years identified over 200 randomised trials. Interventions targeting diet, activity (including physical activity and sedentary behaviours) and both diet and activity appear to have small but beneficial effects on average. However, these effects varied between studies and might be explained by variation in characteristics of the interventions, for example, by the extent to which the children enjoyed the intervention or whether they aim to modify behaviour through education or physical changes to the environment. Here we develop a novel analytic framework to identify key intervention characteristics considered likely to explain differential effects. Objectives To describe the development of the analytic framework, including the involvement of school-aged children, parents, teachers and other stakeholders, and to present the content of the finalised analytic framework and the results of the coding of the interventions. Design and methods We first conducted a literature review to find out from the existing literature what different types of characteristics of interventions we should be thinking about and why. This information helped us to develop a comprehensive map (called a logic model) of these characteristics. We then used this logic model to develop a list of possible intervention characteristics. We held a series of workshops with children, parents, teachers and public health professionals to refine the list into a coding scheme. We then used this to code the characteristics of each intervention in all the trials which aimed to prevent obesity in children aged 5–18 years. Findings Our finalised analytic framework included 25 questions across 12 characteristics. These addressed aspects such as the setting of the intervention (e.g. at school, at home or in the community), mode of delivery (e.g. to individuals or to groups of children), whether the intervention targeted diet and/or activity, complexity (e.g. focused on a single swap of juice for water or aimed to change all aspects of the diet), intensity, flexibility, choice, mechanism of action (e.g. through participation, education, change in the social environment, change in the physical environment), resonance (e.g. credibility of the person delivering the intervention), commercial involvement and the ‘fun factor’ (as perceived by children). We coded 255 interventions from 210 randomised trials. Conclusions Our evidence-based analytic framework, refined by consulting with stakeholders, allowed us to code 255 interventions aiming to prevent obesity in children aged 5–18 years. Our confidence in the validity of the framework and coding results is increased by our rigorous methods and, especially, the involvement of children at multiple stages.

Aims: Public health intervention research increasingly adopts a complex systems approach, viewing interventions as events in systems that must adapt to evolving circumstances for sustainability. This study examines how a process of self-evaluation guided by the Action Scales Model (ASM) can enhance adaptive capacity in intervention programmes. Methods: This study reports on the experiences from the Child Life in Healthy Balance (CLHB) programme. Data sources include participant observations, interviews, meeting minutes, and implementation logs from programme developers, project leaders, and local practitioners collected between 2020 and 2024. Observations examined engagement with the ASM during workshops and implementation activities, while interviews illustrated practitioners’ understanding of programme goals and implementation. Meeting minutes documented programme planning and self-evaluation discussions, and implementation logs showed progress and signs of change derived from the programme. Results: Through practice examples from the CLHB, we demonstrate how the ASM was used as a self-evaluative tool among programme developers and project leaders, as well as a framework for participatory evaluation and communication of programme goals to local practitioners. We highlight signs of capacity building and system change. The ASM facilitated structured discussions on implementation progress and helped align and adjust actions with programme goals. Although practitioners were not always explicitly aware of the ASM, interviews revealed that their understanding of programme goals was aligned with the terminology of the ASM and the overall principles of a systems approach. Some inconsistencies in interpreting the model created uncertainties, yet ASM proved valuable for communicating programme strategies and engaging local practitioners. Conclusion: The ASM helped align actions with CLHB programme goals, fostering adaptive capacity by reframing and aligning perspectives. These positive experiences suggest that the ASM can be a useful tool for self-evaluation to enhance capacity-building efforts in systems-oriented community health interventions.

Background Childhood obesity is a major public health concern worldwide, yet the best way to prevent it remains unknown. Objective(s) To determine what types of intervention strategy are most effective at preventing the development of obesity in children aged 5–18 years, as measured by change in body mass index, and to determine whether interventions work differentially in children with different characteristics associated with inequities. Design Systematic reviews and statistical evidence syntheses. Eligibility criteria Randomised controlled trials of dietary and/or activity interventions that aimed to prevent overweight or obesity in children and young people aged 5–18 years and reported outcomes at least 12 weeks after baseline. Non-randomised evidence was identified through an overview of systematic reviews. Sources of inequity of interest were those defined by the PROGRESS (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital) acronym: place, race/ethnicity, occupation (of parents), gender/sex, religion, education (of parents), socioeconomic status and social capital. Data sources Updating of an existing Cochrane Review, searching bibliographic databases up to February 2023, including MEDLINE, EMBASE, PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials on the Cochrane Library, international trial registers and grey literature databases, and examining reference lists. Results subgrouped by inequity factors were sought directly from trialists. Review methods Cochrane Reviews followed standard Cochrane procedures. The main statistical synthesis was informed by a novel analytic framework developed iteratively through discussions with children and young people, schoolteachers and public health professionals. Methodology was developed to analyse the data using multilevel metaregression. To examine the impact of inequity factors, we performed a two-stage meta-analysis of interactions, based on subgroup-level aggregate data collected directly from the trialists. We collected available information on intervention costs. Results We included 172 trials in ages 5–11 and 74 in ages 12–18. In the main synthesis, of 204 trials from both reviews, we found interventions were effective on average (mean difference in standardised body mass index −0.037, 95% credible interval −0.053 to −0.022, which would correspond to a reduction in a proportion of 2.3% with obesity to a proportion of approximately 2.1%). Larger effects were associated with physical activity rather than dietary interventions, after 12 months of follow-up and in the older age group. The overview of non-randomised evidence included 24 systematic reviews, yielding mixed results. The investigation of inequity did not identify substantial differences in effectiveness according to place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital characteristics, and there was very limited information about costs. Limitations We were able to examine only the interventions that had been evaluated in studies identified for inclusion in the systematic reviews, which does not cover all possible intervention approaches. Conclusions Interventions to prevent obesity in children aged 5–18 have a small beneficial effect on body mass index on average but with considerable variation. A novel re-analysis of existing randomised trials failed to identify general intervention characteristics driving this variation. No evidence was identified to suggest that interventions increase (or decrease) health inequities. Future work Future studies of the effects of interventions to prevent childhood obesity should routinely collect baseline characteristics around potential inequities. Funding This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131572.

Poor behaviour in UK secondary schools is considered a significant problem. While the Department for Education recommends disciplinary behaviour management strategies (DBMS), their impact on pupil mental health and wellbeing, as well as their effectiveness in addressing poor behaviour, remains unclear. Young people aged 13–18 years were recruited to a study using peer-led semi-structured interviews, analysed using the Framework Method. Fifteen interviews were conducted and analysis showed that participants found DBMS to be confusing, unfair, harsh and inconsistent. They were seen as ineffective for addressing poor behaviour and as negatively affecting pupil mental health and wellbeing, and academic and social outcomes. Participants viewed DBMS, especially the use of isolation, as ineffective and potentially harmful. They suggested that school leaders should review their behaviour management policies and consider the adoption of approaches that build relationships and seek to understand the reasons for poor behaviour.

BACKGROUND: Randomised controlled trials (RCTs) are often regarded as the gold standard of evidence, and subsequently go on to inform policymaking. Cochrane Reviews synthesise this type of evidence to create recommendations for practice, policy, and future research. Here, we critically appraise the RCTs included in the childhood obesity prevention Cochrane Review to understand the focus of these interventions when examined through a wider determinants of health (WDoH) lens. METHODS: We conducted a secondary analysis of the interventions included in the Cochrane Review on "Interventions for Preventing Obesity in Children", published since 1993. All 153 RCTs were independently coded by two authors against the WDoH model using an adaptive framework synthesis approach. We used aspects of the Action Mapping Tool from Public Health England to facilitate our coding and to visualise our findings against the 226 perceived causes of obesity. RESULTS: The proportion of interventions which targeted downstream (e.g. individual and family behaviours) as opposed to upstream (e.g. infrastructure, environmental, policy) determinants has not changed over time (from 1993 to 2015), with most intervention efforts (57.9%) aiming to change individual lifestyle factors via education-based approaches. Almost half of the interventions (45%) targeted two or more levels of the WDoH. Where interventions targeted some of the wider determinants, this was often achieved via upskilling teachers to deliver educational content to children. No notable difference in design or implementation was observed between interventions targeting children of varying ages (0-5 years, 6-12 years, 13-18 years). CONCLUSIONS: This study highlights that interventions, evaluated via RCTs, have persisted to focus on downstream, individualistic determinants of obesity over the last 25 years, despite the step change in our understanding of its complex aetiology. We hope that the findings from our analysis will challenge research funders, researchers, policymakers and practitioners to reflect upon, and critique, the evidence-based paradigm in which we operate, and call for a shift in focus of new evidence which better accounts for the complexity of obesity.

Childhood obesity remains a major public health and social issue. Its’ prevalence has grown significantly over the last 30 years and is expected to rise further in future years. The physical, psychological, social and emotional consequences of obesity are significant on both the individual and society as a whole. There is a strong evidence base for the treatment of childhood obesity, with many reviews suggesting that weight management (WM) programs can be both effective and cost effective. That said, data on longer term efficacy is currently limited. This article sets out to discuss a range of WM programs and their component parts, how to ensure appropriate services are referred to, and distil the evidence base around effectiveness. We also place WM in the context of the wider political systems those which fundamentally shape the offers available to families in need. Despite evidence highlighting the widespread impacts of obesity on individuals and society, WM service provision remains limited. In part, this may be due to the complexity of obesity, and as a result, we close the article by discussing WM programs as part of a whole systems approach.

Abstract

Background: Systems approaches are currently being advocated and implemented to address complex challenges in Public Health. These approaches work by bringing multi-sectoral stakeholders together to develop a collective understanding of the system, and then to identify places where they can leverage change across the system. Systems approaches are unpredictable, where cause-and-effect cannot always be disentangled, and unintended consequences – positive and negative – frequently arise. Evaluating such approaches is difficult and new methods are warranted. Methods: Ripple Effects Mapping (REM) is a qualitative method which can capture the wider impacts, and adaptive nature, of a systems approach. Using a case study example from the evaluation of a physical activity systems approach in Gloucestershire, we: a) introduce the adapted REM method; b) describe how REM was applied in the example; c) explain how REM outputs were analysed; d) provide examples of how REM outputs were used; and e) describe the strengths, limitations, and future uses of REM based on our reflections. Results: Ripple Effects Mapping is a participatory method that requires the active input of programme stakeholders in data gathering workshops. It produces visual outputs (i.e., maps) of the programmes activities and impacts, which are mapped along a timeline to understand the temporal dimension of systems change efforts. The REM outputs from our example were created over several iterations, with data collected every 3-4 months, to build a picture of activities and impacts that have continued or ceased. Workshops took place both in person and online. An inductive content analysis was undertaken to describe and quantify the patterns within the REM outputs. Detailed guidance related to the preparation, delivery, and analysis of REM are included in this paper. Conclusion: REM may help to advance our understanding and evaluation of complex systems approaches, especially within the field of Public Health. We therefore invite other researchers, practitioners and policymakers to use REM and to continuously evolve the method to enhance its application and practical utility.

Abstract

Following publication of the original article [1], the authors identified that the funding section was incomplete. The incorrect and correct funding section is shown below. The original article has been updated.

Background Engaging in regular physical activity requires continued complex decision-making in varied and dynamic individual, social and structural contexts. Widespread shortfalls of physical activity interventions suggests the complex underlying mechanisms of change are not yet fully understood. More insightful process evaluations are needed to design and implement more effective approaches. This paper describes the protocol for a process evaluation of the JU:MP programme, a whole systems approach to increasing physical activity in children and young people aged 5–14 years in North Bradford, UK. Methods This process evaluation, underpinned by realist philosophy, aims to understand the development and implementation of the JU:MP programme and the mechanisms by which JU:MP influences physical activity in children and young people. It also aims to explore behaviour change across wider policy, strategy and neighbourhood systems. A mixed method data collection approach will include semi-structured interview, observation, documentary analysis, surveys, and participatory evaluation methods including reflections and ripple effect mapping. Discussion This protocol offers an innovative approach on the use of process evaluation feeding into an iterative programme intended to generate evidence-based practice and deliver practice-based evidence. This paper advances knowledge regarding the development of process evaluations for evaluating systems interventions, and emphasises the importance of process evaluation.

PURPOSE: Psychosocial interventions (PSIs) are characterized by three phases: (1) an initial in-depth assessment, (2) an intensive multifaceted intervention to stem a condition, and (3) an extensive maintenance program. PSIs are often used for treatment of mental health conditions; however, applicability in the treatment of adolescent obesity is unknown. This article sought to evaluate the service-level outcomes of a PSI for young people (aged 10-17) with severe obesity. METHODS: A retrospective evaluation of participants attending the Self Help, Independence, Nutrition and Exercise program between 2011 and 2016 (n = 435; age: 13.1 ± 2.1 years, male: 51%, white: 87.4%, body mass index [BMI]: 33.5 ± 7.5 kg/m(2), standardized BMI [BMI SDS]: 3.1 ± .5 units). Anthropometric measurements (BMI and waist circumference) were collected at baseline, 3, 6, 9, and 12 months. Psychosocial measures (anxiety, depression, and self-esteem) were collected at baseline and 3 months. Participant retention was also assessed. RESULTS: After 3 months, 95% of participants remained with a mean BMI SDS reduction of .19 units (95% confidence interval: .17, .21). Anxiety, depression, and self-esteem improved by 50%, 54%, and 38%, respectively. BMI SDS reductions of .29, .35, and .41 units were found at 6, 9, and 12 months. Fifty-four percent of participants chose to attend the final intervention phase. A higher baseline BMI SDS and a greater reduction in BMI SDS predicted final intervention phase attendance. CONCLUSIONS: The Self Help, Independence, Nutrition and Exercise PSI demonstrated positive mean reductions in all measurements across all time points. In contrast to other community-based weight management services, these results suggest the utility of, and further exploration of, PSIs in the treatment of severe adolescent obesity.

This report accompanies a guide and set of resources to support local authorities in implementing a whole-systems approach to addressing obesity and promoting healthy weight from Public Health England.

Background: Systems thinking is integral to working effectively within complex systems, such as those which drive the current population levels of overweight and obesity. It is increasingly recognised that a systems approach – which corrals public, private, voluntary and community sector organisations to make their actions and efforts coherent – is necessary to address the complex drivers of obesity. Identifying, implementing and evaluating actions within complex adaptive systems is challenging, and may differ from previous approaches used in public health. Methods: Within this conceptual article, we present the Action Scales Model (ASM). The ASM is a simple tool to help policymakers, practitioners and evaluators to conceptualise, identify and appraise actions within complex adaptive systems. We developed this model using our collective expertise and experience in working with local government authority stakeholders on the Public Health England Whole Systems Obesity programme. It aligns with, and expands upon, previous models such as the Intervention Level Framework, the Iceberg Model and Donella Meadows’ 12 places to intervene within a system. Results: The ASM describes four levels (synonymous with leverage points) to intervene within a system, with deeper levels providing greater potential for changing how the system functions. Levels include events, structures, goals and beliefs. We also present how the ASM can be used to support practice and policy, and finish by highlighting its utility as an evaluative aid. Discussion: This practical tool was designed to support those working at the front line of systems change efforts, and while we use the population prevalence of obesity as an outcome of a complex adaptive system, the ASM and the associated principles can be applied to other issues. We hope that the ASM encourages people to think differently about the systems that they work within and to identify new and potentially more impactful opportunities to leverage change.

Purpose: Psychosocial Interventions (PSI) are commonly utilised in mental health management, and to our knowledge, have not been explicitly used in weight management. PSI are characterised by three distinct phases: 1) an initial in-depth assessment; 2) an intensive group intervention to stabilise the condition (in this instance weight gain); and 3) an intensive group maintenance programme. PSI focus on the psychosocial elements of obesity, including: stress management, body dysmorphia and self-esteem. As such, the PSI approach is more holistic than traditional weight management approaches. This paper evaluated the outcomes of a PSI when delivered under service level conditions. Methods: SHINE (Self-Help, Independence, Nutrition, and Exercise) is a community-based weight management programme that implements a PSI approach. The programme is located in Sheffield, UK. Adolescents (n = 393) with severe obesity signed onto the programme between 2011 and 2013. The programme spans 12-15 months and participants attend three phases of the PSI. Phase One is undertaken before the programme, Phase Two is a 12-week intervention and Phase Three is split into three 12-week maintenance interventions. Anthropometric measurements (BMI and WC) were collected at baseline, 3-, 6-, 9- and 12-months. Psychosocial measures (self-esteem, anxiety and depression) were collected at baseline and 3-months. Participant retention was also assessed. Results: 304 participants started the programme and 289 were retained at 3 months. At 3 months BMI z-score reduced by 0.21 (95% CI: 0.19, 0.24) and WC by 7.8cm (95% CI: 7.2, 8.5). Almost 25% of participants reduced their BMI classification (e.g. severely obese to obese). Anxiety and self-esteem improved by 63% and 50% respectively. 89 participants continued to attend the programme after 12 months, obtaining a BMI z-score reduction of 0.46 (95% CI: 0.35, 0.58) and a WC reduction of 10.5cm (95% CI: 7.8, 13.1). Conclusions: Obesity is a highly complex condition to manage and requires intensive and prolonged support to produce meaningful and lasting behavioural and anthropometric changes. The SHINE PSI approach has shown promise and demonstrated encouraging results - suggesting that it may be beneficial for interventions to consider wider determinants of health and wellbeing beyond simply diet and physical activity.

Whole systems approaches are increasingly being advocated as a way of responding to complex public health priorities such as obesity and physical inactivity. Due to the complex and adaptive nature of such systems, researchers are increasingly being embedded within host organisations (i.e., those which facilitate the whole systems approach) to work with key stakeholders to illuminate and understand mechanisms of change and develop a culture of continuous improvement. While previous literature has reported on the benefits and challenges of embedded researchers in health care, little is known about the experiences and learnings of those situated within these complex whole systems approaches. In this paper, we present our reflections of being embedded researchers within four distinct whole systems approaches and outline recommendations and considerations for commissioners working with or seeking support from an embedded researcher.

Background Systems approaches are currently being advocated and implemented to address complex challenges in Public Health. These approaches work by bringing multi-sectoral stakeholders together to develop a collective understanding of the system, and then to identify places where they can leverage change across the system. Systems approaches are unpredictable, where cause-and-effect cannot always be disentangled, and unintended consequences – positive and negative – frequently arise. Evaluating such approaches is difficult and new methods are warranted. Methods Ripple Effects Mapping (REM) is a qualitative method which can capture the wider impacts, and adaptive nature, of a systems approach. Using a case study example from the evaluation of a physical activity-orientated systems approach in Gloucestershire, we: a) introduce the adapted REM method; b) describe how REM was applied in the example; c) explain how REM outputs were analysed; d) provide examples of how REM outputs were used; and e) describe the strengths, limitations, and future uses of REM based on our reflections. Results Ripple Effects Mapping is a participatory method that requires the active input of programme stakeholders in data gathering workshops. It produces visual outputs (i.e., maps) of the programme activities and impacts, which are mapped along a timeline to understand the temporal dimension of systems change efforts. The REM outputs from our example were created over several iterations, with data collected every 3–4 months, to build a picture of activities and impacts that have continued or ceased. Workshops took place both in person and online. An inductive content analysis was undertaken to describe and quantify the patterns within the REM outputs. Detailed guidance related to the preparation, delivery, and analysis of REM are included in this paper. Conclusion REM may help to advance our understanding and evaluation of complex systems approaches, especially within the field of Public Health. We therefore invite other researchers, practitioners and policymakers to use REM and continuously evolve the method to enhance its application and practical utility.

This paper introduces the Qualitative Systems Exploration Model (QSEM), a new semi-quantitative framework for systematically interpreting and analysing Causal Loop Diagrams within participatory system dynamics. QSEM is applied at late-stage model conceptualisation and offers researchers and modelling practitioners a set of tools and techniques to improve transparency and reproducibility in model assessment, ensuring that component and feedback structure selections are traceable and well-justified. Throughout its three core phases: (i) System Factor Classification; (ii) Loops of Interest; and, (iii) Archetype Identification and Analysis, QSEM integrates with established Group Model Building scripts to facilitate structured participant engagement and collaborative sensemaking. Real-world application is demonstrated in a commissioned government project aimed at understanding factors influencing dietary choices and food systems, where the framework helped identify potential policy-relevant system drivers. Future directions involve applying QSEM in other projects, evaluating its robustness, consistency and scalability, refining archetype detection, enhancing data visualisation, and exploring dedicated software solutions to expand its utility in qualitative SD.

Childhood obesity remains a major public health and social issue. Its’ prevalence has grown significantly over the last 30years and it is expected to rise further in future years. The physical, psychological, social, emotional, and economic consequences of obesity are significant on both the individual and society as a whole. There is a moderate evidence base for the treatment of childhood obesity, with many reviews suggesting that weight management (WM) programs can be both effective and cost effective. That said, data on longer term efficacy is currently limited, as is that for specialist weight management services and pharmacotherapy. This chapter sets out to discuss a range of WM programs and their component parts, how to ensure appropriate services are referred to, and distill the evidence base around effectiveness. We also place WM in the context of the wider political systems in the UK – those which fundamentally shape the offer available to families in need. In this Edition 3 update, we highlight recent advancements and contemporary issues in childhood WM provision.

Introduction: Interventions are often developed without the guidance of the target group to be worked with. Action research (programme development with the input of researchers and clients) has been highlighted as a useful method for increasing programme engagement and achieving programme outcomes [1]. Hearty Lives Renfrewshire (HLR), is a British Heart Foundation a community-based intervention aiming to increase knowledge and awareness of CVD risk factors in young people, adopted an action research methodology. HLR delivers a school-based intervention to young people aged 13-16; this intervention was developed by the young people, with elements of the intervention delivered by the young people. Objectives: To evaluate the use of an action research approach to designing, developing and delivering HLR. Method: Semi-structured interviews with stakeholders (n = 5, 22-56 minutes), and focus groups interviews with participants [attending the HLR intervention] (n = 9, 15 minutes). Interviews were recorded and transcribed verbatim. Thematic analysis was used to analyse the data. Results: Students suggested they felt empowered when consulted with about improving and refining the programme. The HLR delivery team were responsive to participant ideas and facilitated the implementation of ideas. Intervention content was also refined to become more engaging – this was a product of participant feedback. To increase programme reach, a Parkour (acrobatic free running) club was set up which had health messages embedded in its design. All participants cited an improved knowledge, yet behaviour change was less apparent. Conclusion: HLR successfully engaged with participants in all stages of the intervention. Moreover, the programme expanded using alternate modes of delivery (e.g. Parkour) to engage a traditionally hard-to-engage demographic. Action Research should be considered when designing, developing and refining an intervention rather than a traditional problem-solution orientated approach.

Introduction: Looked After Children (LAC) are some of the most vulnerable and socially excluded in society (Golding, 2008). Hearty Lives (HL) is £1.2 million British Heart Foundation project designed to reduce health inequalities by supporting those at greatest risk of cardiovascular disease. Two of the six sites focussed on addressing inequalities specifically in children in the social care context. Objectives: The research aimed to gather stakeholders’ views in the design, development and refinement of the HL, health promotion intervention (HP based interventions) to ensure they were acceptable and feasible for LAC and/or carers. Method: 14 qualitative semi-structured interviews were conducted with stakeholders. Interviews explored views towards the HL intervention and what they felt were the key factors to consider in designing HP interventions in the social care context. Results: Stakeholder views revealed two approaches to working with LAC. One approach was to develop an in-house intervention that targeted LAC and care home workers in a safe, familiar environment. Stakeholders believed the key to this approach was taking time to build trust and rapport with the children which increased the likelihood of children engaging and adhering to the HP intervention. Stakeholders suggested a second, more cost and time effective, approach was to target LAC carers and home workers directly. The carers could then filter and transfer the healthy lifestyle/educational messages to LAC. This removed barriers to accessing LAC. Conclusions: Stakeholders views suggest that both in-house interventions and interventions targeted at LAC workers are acceptable and feasible approaches to working with LAC. Their views suggest that targeting LAC workers could be a more sustainable method of delivering HP interventions. Further research is needed to establish the effectiveness of different approaches to engaging LAC in health promotion.

Introduction: Hearty Lives (HL) is a £1.2 million programme established by the British Heart Foundation which aims to reduce health inequalities, particularly by supporting those ‘at greatest risk’ of Cardiovascular Disease (CVD). Six programmes have been set up (Adur, Glasgow, Liverpool, Manchester, Renfrewshire & Wolverhampton) to reduce the incidence of CVD risk factors in children and young people (aged 11-18 years old). Leeds Beckett University (LBU) is conducting the national three-year evaluation of the HL programmes. Objectives: The national evaluation aims to extract key learnings and provide recommendations for working with vulnerable populations (at greater risk of CVD). This is done through an action research methodology. Methods: Within this action research approach, a case study methodology has been used to recognise the uniqueness of each HL project. Impact and process outcomes are being collected to assess HL intervention effectiveness and to establish what processes led to the success or shortcomings of each approach. Key stakeholders views towards HL interventions were captured. Results: The evidence produced from the first year fed into the refinement and development of each of the six HL interventions in the second year. The 6 HL interventions have considered stakeholders views in order to develop tailored and flexible HP interventions. This is considered key when addressing health disparities (Jacobs et al., 2012). All HL interventions recognise the importance of planning for sustainability and putting strategies in place to ensure that they can be continued beyond the three year funding. Developing links with partners, delivering training to multiple stakeholders and accessing other sources of funding are key to consider in the sustainability of such HP interventions. Conclusion: This research highlights the benefits of a collaborative action research approach. It identifies the value of evaluation teams working alongside stakeholders to refine and develop feasible, acceptable and efficacious HP interventions.

Background: The Systems Evaluation Network (SEN) aims to build capability and capacity regarding the use of systems science in public health evaluation. The SEN was established in June 2021 and 3 years from its inception, we undertook a member survey to understand the engagement with, and impact of, the SEN. Methods: An 18-item cross-sectional survey captured quantitative and qualitative responses regarding SEN member perspectives, centring around their experience of the SEN, associated impacts, and future requirements. We analysed quantitative data descriptively and qualitative data through content analysis. Sub-group analyses explored differences between those working in academia vs practice/policy. Results: Seventy-three participants completed the survey, with 60% working in academia and 40% in practice/policy. Considering experiences of the SEN, participants felt the SEN has shared information about innovative methods and evaluation approaches (94.0% agreed), has provided the opportunity to share and learn with other members (86.0% agreed), and has improved knowledge of systems evaluation methods (86.2% agreed). Regarding impacts of the SEN, participants stated that the SEN has increased their capability to apply systems-oriented methods and evaluation of systems approaches (76% agreed) and has facilitated relationships with others (56.9% agreed). Participants shared future capability requirements for evaluation, which focused on methods (e.g. systems dynamics modelling and ripple effects mapping), approaches (e.g. developmental evaluation and embedded researchers), and other ways in which capability could be increased (e.g. by using case studies). Conclusion: This paper illustrates the experiences and impacts of the SEN, identifying its strengths such as the wide range of topics/content and the flexible and accessible delivery format, but contrast against the difficulties of fostering new relationships in an online setting. These findings can help inform the future direction of the SEN and provide insight to other online communities of practice.

Purpose: The criteria for participant completion of a weight management programme (WMP) is arbitrary. Programme commissioners (WMP purchasers) will frequently establish the percentage of attendance that classifies programme completion (e.g. 70% attendance). Differential criteria for WMP completion make it impossible for researchers, practitioners and policy makers to conclude what constitutes an effective programme and what factors predict WMP completion. This study exemplifies the impact of variable completion status on 1) BMI reduction, 2) volume of completers and 3) predictors of completion. Methods: Secondary data was obtained from MoreLife – a UK-based, community WMP for children (aged 4-17 years). 2948 children attended between 2009-2014 (Age 10.4±2.8 years, BMI 26.0±5.7kg/m2, Standardised BMI (BMI SDS) 2.48±0.87 units, White 70.3%). Separate analyses were conducted for research aims 1-2, and aim 3. Programme completion was adjusted incrementally by 10% (i.e. 10%, 20% attendance etc…) for research aims 1-2. The volume of programme completers and change in BMI SDS was calculated at each increment of the completion criteria (0-100%). For aim 3, programme completion was defined using five classifications from previous WMP studies (e.g. 50% sessions attended). Multivariable logistic regression determined participant and programme variables predictive of programme completion. Percentage difference between the odds ratio of the original model (completion = 70% attendance) and the four subsequent models was calculated. Results: The volume of participants completing the programme decreased in a linear manner (r = -0.99, p = 0.00) when completion classification became more stringent (i.e. 70-100% attendance). Conversely, the change in BMI SDS became incrementally greater (r = 0.98, p = 0.00). Predictors of completion varied by up to 24.2% in certain variables (e.g. Programme Intake Period) when using five different completion classifications. Statistical significance of the predictor variables were reliant on completion classification (e.g. WMP Group Size was significant in two of five models). Conclusions: The volume of completers and change in BMI SDS were strongly associated with programme completion classification. Poor programme outcomes (e.g. minimal change in BMI SDS) can be masked by (un)demanding completion criteria. Moreover, completion criteria mediates participant and programme characteristics predictive of programme completion. Standardised completion criteria are called for.

BACKGROUND: Approximately 50% of participants complete a paediatric weight management programme, yet the predictors of attendance and dropout are inconsistent. This study investigates subject and intervention-design characteristics associated with attendance at a group based, family weight management programme. SETTING AND SUBJECTS: Secondary data analysis of 2948 subjects (Age 10.4±2.8 years, BMI 26.0±5.7kg/m2, Standardised BMI (BMI SDS) 2.48±0.87, White 70.3%) from 244 MoreLife (UK) programmes. Subjects attend weekly for 10-12 weeks, sessions last 2-3 hours. Sessions include lifestyle guidance and physical activity. METHOD: Subject characteristics (demographics, psychological (body satisfaction & self-esteem) and sedentary behaviour) were gathered at first contact and BMI SDS was noted weekly. Intervention-design characteristics were recorded (year, length (weeks), group size, age segregation and day of session). Attendance was calculated as total number of sessions attended (%). Multivariate linear regression examined predictors of attendance and multiple imputation countered missing data. RESULTS: Average attendance was 59.4%±29.3%. Baseline subject characteristics were ‘poor’ predictors of attendance. Intervention year, group size and day of session significantly predicted attendance (Tables 1 & 2). Yet, the most predictive marker of attendance was a change in BMI SDS during the programme (B = -0.38, 95% CI = -0.43 - -0.33). CONCLUSION: A reduction in BMI was seen to predict greater attendance. However, baseline subject characteristics were weakly associated with attendance, refuting past findings. Dominant intervention characteristics (large groups, weekend sessions and recent delivery) predicted lower attendance. Future programmes may be better informed.

Objectives: Current research in the field of childhood weight management (WM) effectiveness is hampered by inconsistent terminology and criterion for WM programme completion, alongside other engagement-related concepts (e.g. adherence, dropout, and attrition). Evidence reviews are not able to determine conclusive intervention effectiveness because of this issue. This study aims to quantify how various completion criterion impact upon on: 1) the percentage of WM completers; 2) the standardised Body Mass Index (BMI SDS) reduction; and 3) the predictors of WM completion. Study Design: A methodological, sensitivity analysis to examine how differential completion criteria affect programme outcomes and predictors. Methods: Secondary data of 2948 children were used. All children attended a MoreLife WM programme between 2009 and 2014. The completion criterion was incrementally adjusted by 10% (i.e. completer attends 10%, 20%, 30%... of sessions) for research aims 1-2, with the percentage of completers and change in BMI SDS calculated at each increment. For aim 3, the stability (strength, direction, and significance) of the predictors were examined when using the completion criterion of four alternative studies against our previous study (completion ≥70% attendance). Results: The volume of programme completers decreased in a linear manner as the completion criterion became more stringent (i.e. 70-100% attendance). The change in BMI SDS conversely became incrementally greater. The strength, direction, and significance of the predictors was highly dependent on the completion criterion; the odds ratio varied by 24.2% across a single predictor variable (delivery period). The degree of change is evidenced in the paper. Conclusions: Inconsistent completion criterion greatly limits the synthesis of programme effectiveness, and explains some of the inconsistency in the predictors of engagement. Standardised criterion for engagement-related terminology are called for.

BACKGROUND: Approximately 50% of paediatric weight management (WM) programme attendees do not complete their respective programmes. High attrition rates compromise both programme effectiveness and cost-efficiency. Past research has examined pre-intervention participant characteristics associated with programme (non-)completion, however study samples are often small and not representative of multiple demographics. Moreover, the association between programme characteristics and participant engagement is not well known. This study examined participant and programme characteristics associated with engagement in a large, government funded, paediatric WM programme. Engagement was defined as the family's level of participation in the WM programme. METHODS: Secondary data analysis of 2948 participants (Age: 10.44 ± 2.80 years, BMI: 25.99 ± 5.79 kg/m(2), Standardised BMI [BMI SDS]: 2.48 ± 0.87 units, White Ethnicity: 70.52%) was undertaken. Participants attended a MoreLife programme (nationwide WM provider) between 2009 and 2014. Participants were classified into one of five engagement groups: Initiators, Late Dropouts, Low- or High- Sporadic Attenders, or Completers. Five binary multivariable logistic regression models were performed to identify participant (n = 11) and programmatic (n = 6) characteristics associated with an engagement group. Programme completion was classified as ≥70% attendance. RESULTS: Programme characteristics were stronger predictors of programme engagement than participant characteristics; particularly small group size, winter/autumn delivery periods and earlier programme years (proxy for scalability). Conversely, participant characteristics were weak predictors of programme engagement. Predictors varied between engagement groups (e.g. Completers, Initiators, Sporadic Attenders). 47.1% of participants completed the MoreLife programme (mean attendance: 59.4 ± 26.7%, mean BMI SDS change: -0.15 ± 0.22 units), and 21% of those who signed onto the programme did not attend a session. CONCLUSIONS: As WM services scale up, the efficacy and fidelity of programmes may be reduced due to increased demand and lower financial resource. Further, limiting WM programme groups to no more than 20 participants could result in greater engagement. Baseline participant characteristics are poor and inconsistent predictors of programme engagement. Thus, future research should evaluate participant motives, expectations, and barriers to attending a WM programme to enhance our understanding of participant WM engagement. Finally, we suggest that session-by-session attendance is recorded as a minimum requirement to improve reporting transparency and enhance external validity of study findings.

Summary Background Prevalence of both obesity and type 2 diabetes can be higher in patients from certain ethnic groups, yet uptake and adherence to current support within these groups is lower, leading to widening health inequalities in high‐income countries. Objectives The main objective of this study is to understand the views, perceptions, and experiences of and barriers and facilitators in relation to the uptake and adherence to weight management and type 2 diabetes programs in minoritized ethnic groups in high‐income countries. Methods CINAHL, MEDLINE, PsycINFO, Scopus, Academic Search Complete, and PubMed were searched for English language studies undertaken in community‐dwelling adults residing in high‐income countries, who are from a minoritized ethnic group within the country of study. Results Seventeen studies were synthesized using the JBI System for the Unified Management of the Assessment and Review of Information. From these studies, 115 findings were retrieved, and seven key themes were identified: (1) family health status and program education, (2) social support, (3) challenges, (4) cultural beliefs, (5) increased awareness and dietary changes, (6) impact of psychological evaluations, and (7) considerations for future. Conclusions Nutritional considerations for type 2 diabetes mellitus and weight management programs in high‐income countries should include social, habitual, economic, and conceptual components, which should include consideration of local ethnic and cultural norms and building community relationships while creating culturally tailored programs.

Purpose: Approximately 50% of families who initiate a weight management programme (WMP) will not complete. It is fundamental to understand why participants initiate and complete a programme, and to ensure that programmes are effectively designed and delivered. This study examined the reasoning for family (young person and parent) engagement in three different and diverse WMPs. Methods: A multiple instrumental case study approach was employed. Three community-based WMPs participated: MoreLife, SHINE, and Weigh to Go. Clear design and implementation differences existed between WMPs. Multiple WMPs were recruited to examine the generalisability of research findings, and extract key features associated with participant engagement. Thirty families took part (~10 per programme). Data were collected early in the programme (0-2 weeks) and immediately after completion or dropout (within two weeks). Young people took part in a Participatory Action Research (PAR) session (interactive activities to generate meaningful information), and parents completed semi-structured interviews. A deductive line of inquiry was used; questions were based upon participant characteristics, environmental interactions, psychological processes and programme interactions. Interview data was transcribed verbatim and analysed alongside the PAR data using content and thematic analysis (themes presented in italics). Results: Preliminary findings indicate that families often engage in a WMP for non-weight related reasons. Such reasons include: management of mental health, to improve self -esteem, and to create friendships. Families remain in a WMP when: the programme suits their needs, they fit in amongst other participants, strong relationships are fostered with staff, and have strong support networks. Numerous families completing programmes prioritised WMP attendance above other leisure activities, and had plans in place to ensure they could attend each session. Low engagement was due to situational factors (e.g. logistic barriers [transport, timing…]) rather than programme dissatisfaction. Conclusions: Families attend community-based WMPs for reasons beyond weight management. Additionally, the families identified unique WMP features (e.g. maintenance programmes and non-clinical staff) which encourage programme attendance. Such features can be replicated in multiple, diverse settings. Understanding participant engagement is critical to designing and implementing efficacious WMPs.

Background: Childhood weight management programmes (WMP) are used within the UK to stem the rising prevalence of pediatric obesity. These WMPs often provide children and young people (CYP) and their family’s with methods of stabilising and reducing the severity of the weight issue. That said, low engagement in WMPs is often encountered but the reasoning is not well known. Misaligned and unrealistic outcome expectations have been hypothesised as a reason for low engagement. This paper explores 1) the parent and CYP outcome expectations of a WMP, and 2) the qualitative level of agreement between parent and CYP expectations. Methods: 30 families were recruited from three, UK-based WMPs (10 families per programme). Qualitative research methods were used to examine both the parent and CYP outcome expectations. Participatory research methods were used with CYP and semi-structured interviews with parents. Data were collected from parents and CYP independently, and notably, were collected from participants within two weeks of starting a WMP. Data were analysed using thematic analysis. In separate analyses, the alignment between parent and CYP responses were examined. Results: Preliminary findings indicate that parents reported 24 different outcome expectations (varying from ‘anger management’ to ‘weight management [not loss]’ to ‘understanding consequences of obesity’), whilst CYP reported 25 expectations (ranging from ‘aesthetic improvement’ to ‘physical activity opportunities’ to ‘not wanting to attend’). Weight loss was the most cited outcome expectation amongst parents and CYP, however friendship, CYP confidence, dietary education, and the reinforcement of parent messages were also strongly cited. Of note, weight loss was not always cited as the primary outcome expectation. The qualitative level of agreement between CYP and parents shall be reported. Conclusions: Families do not always initiate a WMP for the sole purpose of weight loss and management. Practitioners would benefit from understanding what families hope to achieve during their attendance, and subsequently tailor the programme, comments and feedback to reflect this. By tailoring messages and feedback directly to the family expectations, families may see a greater benefit in WMP attendance and therefore be encouraged to persist in treatment. Attendance and weight-related outcomes are strongly correlated.

© 2019 Elsevier B.V. Local government organisations (LAs) have a major role in the prevention and treatment of obesity in England. This study aims to 1) understand what actions are being taken by LAs to address obesity, and 2) determine how actions counter the perceived causes of obesity when mapped against the Wider Determinants of Health (WDoH) model. Thirty-two LAs were invited to complete an Action Mapping Tool, 10 participated. The tool requires LAs to document actions being implemented locally to address obesity. This then enables LAs to map their actions against the perceived causes of obesity, using the WDoH model as an analytical lens. We collated data from the 10 LAs and used an adapted framework synthesis method for analysis. 280 actions were documented across the 10 LAs; almost 60% (n = 166) targeted Individual Lifestyle Factors (ILF), with 7.1% (n = 20), 16.8% (n = 47) and 16.4% (n = 46) targeting Social and Community Factors (SCF), Living and Working Conditions (LWC) and Wider Conditions (WC) respectively. Conversely, 60% of causes were spread across the LWC and WC, with 16.4% regarded as ILF. Physical activity-, weight management-, and health improvement- programmes were most frequently implemented by LAs. There is a stark mismatch between LA actions on obesity and its perceived causes. Given that LAs acknowledge the complex aetiology of obesity, an equally comprehensive approach should be implemented in the future.

Obesity is a complex problem with multiple causes and significant implications for health and beyond. With the majority of adults in England overweight or obese, and a substantial number of children on the same trajectory, particularly those in the most deprived areas, national and local action is needed now. We know that there is no one single solution. Tackling such an ingrained problem requires a long-term, system-wide approach that makes obesity everybody’s business, is tailored to local needs and works across the life course.

Background: Increasing awareness of the complexity of public health problems, including obesity, has led to growing interest in whole systems approaches (WSAs), defined as those that consider the multifactorial drivers of overweight and obesity, involve transformative co-ordinated action across a broad range of disciplines and stakeholders, operate across all levels of governance and throughout the life course. This paper reports a systematic review of WSAs targeting obesity and other complex public health and societal issues, such as healthy lifestyles for prevention of non-communicable disease. Methods: Seven electronic databases were searched from 1995 to 2018. Studies were included if there had been an effort to implement a WSA. Study selection was conducted by one reviewer with a random 20% double checked. Data extraction and validity assessment were undertaken by one reviewer and checked by a second reviewer. Narrative synthesis was undertaken. Results: 65 articles were included; 33 about obesity. Most examined multicomponent community approaches, and there was substantial clinical and methodological heterogeneity. Nevertheless, a range of positive health outcomes were reported, with some evidence of whole systems thinking. Positive effects were seen on health behaviours, body mass index (BMI), parental and community awareness, community capacity building, nutrition and physical activity environments, underage drinking behaviour and health, safety and wellbeing of community members, self-efficacy, smoking and tobacco-related disease outcomes. Features of successful approaches reported in process evaluations included: full engagement of relevant partners and community; time to build relationships, trust and capacity; good governance; embedding within a broader policy context; local evaluation; finance. Conclusions: Systems approaches to tackle obesity can have some benefit, but evidence of how to operationalise a WSA to address public health problems is still in its infancy. Future research should: (a) develop an agreed definition of a WSA in relation to obesity, (b) look across multiple sectors to ensure consistency of language and definition, (c) include detailed descriptions of the approaches, and (d) include process and economic evaluations.

Obesity is a major public health challenge which continues to increase and disproportionally affects vulnerable population groups, resulting in widening health inequalities. There is consequently an urgent need for innovative approaches to identify and implement evidence-based policy and practice to prevent and treat obesity which has been accelerated by the COVID-19 pandemic. The population levels of obesity are driven by numerous interacting political, economic, environmental, social, cultural, digital, behavioural, and biological determinants. However, causal links between determinants and how they vary between different groups of individuals are not well defined. The identification, implementation, and evaluation of effective responses to the prevention and treatment of obesity require a set of approaches that work within this complexity. The limited efforts to date reflect a misunderstanding of the nature of the chronic and complex nature of obesity, and importantly a limited understanding of how the multifaceted nature of the problem should influence how research, policy, and practice approach it. To date, the evidence underpinning the current approach does not reflect the complexity of the condition: Evidence is largely generated by tools and methods developed to answer questions about the effectiveness of isolated interventions, commonly grounded in linear models of cause and effect. This is the pathway between a cause, for example, exposure to fast food restaurants, and the outcome, obesity, is assumed to be linear, when it is far more complex than this. There is a focus on individual behaviour, yet social and structural determinants of health have a far greater influence on obesity and contribute more to health inequalities. It is acknowledged that we live in an obesogenic environment, yet most approaches to addressing obesity are focused on behaviour change to support individuals adopt healthy weight behaviours, with little (or no) consideration of the environment in which they live. Outcomes are largely measured in the short term and the effects of efforts to reduce population obesity will take many years to be realised. Effectiveness is primarily determined by a narrow focus on weight change, which fails to capture the underlying complexity. Instead of investigating whether a single intervention is (cost-)effective in terms of fixing the problem (i.e. obesity), we need to understand how actions drive positive changes within the system. A systems approach captures and responds to complexity through a dynamic way of working: bringing together academic, policy, practice, and community representatives to develop a ‘shared understanding of the challenge’ and to integrate action to bring about sustainable, long-term systems change. The benefit of a systems approach to addressing population levels of obesity has been outlined: in 2013, the EPODE logic model retrospectively provided insight into the system dynamics of the programme; the ‘Improving the Health of the Public by 2040’ report acknowledged that responses to major public health challenges require a wider set of approaches; in 2017, Rutter et al. called for ‘a complex systems model of evidence for public health’, which was echoed in 2019, as part of The Lancet commission on obesity. More recently, the logic model underpinning the Amsterdam Healthy Weight Approach (AHWA) was published. There are also examples of projects that have embraced system approaches in an applied setting, as well as toolkits, guidance documents, and operational frameworks. These resources demonstrate that the concept of a systems approach to obesity is not new, and importantly that systems methods do not have to replace traditional methods, but instead incorporate and enhance them. Despite this activity and rhetoric, systems approaches are rarely operationalised in ways that generate relevant evidence or effective policies.

Member led symposium at UK Congress on Obesity 2022