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

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

Background: World-wide, health service providers are moving towards innovative models of clinical home-based care services as a key strategy to improve equity of access and quality of care. To optimise existing and new clinical home-based care programs, evidence informed approaches are needed that consider the complexity of the health care system across different contexts. Methods: We present a protocol for working with health services and their partners to perform rapid identification, prioritisation, and co-design of content-appropriate strategies to optimise the delivery of healthcare at home for older people in rural and regional areas. The protocol combines Systems Thinking and Implementation Science using a Consensus Mapping and Co-design (CMC) process delivered over five workshops. Discussion: The protocol will be implemented with rural and regional healthcare providers to identify digital and non-digital solutions that have the potential to inform models of service delivery, improve patient experience, and optimise health outcomes. The combination of system and implementation science is a unique approach for optimising healthcare at home for older populations, especially in the rural context where need is high. This is the first protocol to integrate the use of systems and implementation science into one process and articulating these methods will help with replicating this in future practice. Results of the design phase will translate into practice through standard health service planning methods to enhance implementation and sustainability. The delivery of the protocol will include building capacity of health service workers to embed the design, implementation, and evaluation approach into normal practice. This protocol forms part of the DELIVER (Delivering Enhanced heaLthcare at home through optImising Virtual tools for oldEr people in Rural and regional Australia) Project. Funded by Australia's Medical Research Future Fund, DELIVER involves a collaboration with public health services of Western Victoria, Australia. [ABSTRACT FROM AUTHOR]

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

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

Objective: To determine whether primary school children's weight status and dietary behaviours vary by remoteness as defined by the Australian Modified Monash Model (MMM). Design: A cross-sectional study design was used to conduct secondary analysis of baseline data from primary school students participating in a community-based childhood obesity trial. Logistic mixed models estimated associations between remoteness, measured weight status and self-reported dietary intake. Setting: Twelve regional and rural Local Government Areas in North-East Victoria, Australia. Participants: Data were collected from 2456 grade 4 (approximately 9–10 years) and grade 6 (approximately 11–12 years) students. Results: The final sample included students living in regional centres (17·4 %), large rural towns (25·6 %), medium rural towns (15·1 %) and small rural towns (41·9 %). Weight status did not vary by remoteness. Compared to children in regional centres, those in small rural towns were more likely to meet fruit consumption guidelines (OR: 1·75, 95 % CI (1·24, 2·47)) and had higher odds of consuming fewer takeaway meals (OR: 1·37, 95 % CI (1·08, 1·74)) and unhealthy snacks (OR = 1·58, 95 % CI (1·15, 2·16)). Conclusions: Living further from regional centres was associated with some healthier self-reported dietary behaviours. This study improves understanding of how dietary behaviours may differ across remoteness levels and highlights that public health initiatives may need to take into account heterogeneity across communities. [ABSTRACT FROM AUTHOR]

Introduction: Residents of rural areas internationally typically experience chronic disease risk profiles worse than city dwellers. Poor diet, a key driver of chronic disease, has been associated with unhealthy food environments, and rural areas often experience limited access to healthy, fresh and affordable food. Objective: This study aimed to evaluate the first three years of a health promoting social enterprise café established in a small rural health service. Design: A mixed‐methods evaluation study. Quantitative sales data, surveys and key informant interviews that included both quantitative and qualitative responses. Findings: Three years of sales data were included; 111customer surveys and five key informant interviews were conducted. Food and beverages on displayed and sold consistently met or exceeded the healthy criteria set by policy. Stakeholders supported the traffic light system, the social enterprise model and rated the likelihood of sustainability of the café as high. Discussion: Customers used the 'traffic light' system to inform food choices, placed value on the warmth of the staff and on the welcoming environment created through the social enterprise model. Resources remain tight although all stakeholders are committed to the sustainability of the YarriYak café. Conclusion: The study shows the acceptability, feasibility and sustainability of a health promoting social enterprise café in a rural area. [ABSTRACT FROM AUTHOR]

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

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

Objective: 'Food deserts' and 'food swamps' are food retail environment typologies associated with unhealthy diet and obesity. The current study aimed to identify more complex food retail environment typologies and examine temporal trends. Design: Measures of food retail environment accessibility and relative healthy food availability were defined for small areas (SA2s) of Melbourne, Australia, from a census of food outlets operating in 2008, 2012, 2014 and 2016. SA2s were classified into typologies using a two-stage approach: (1) SA2s were sorted into twenty clusters according to accessibility and availability and (2) clusters were grouped using evidence-based thresholds. Setting: The current study was set in Melbourne, the capital city of the state of Victoria, Australia. Subjects: Food retail environments in 301 small areas (Statistical Area 2) located in Melbourne in 2008, 2012, 2014 and 2016. Results: Six typologies were identified based on access (low, moderate and high) and healthy food availability including one where zero food outlets were present. Over the study period, SA2s experienced an overall increase in accessibility and healthiness. Distribution of typologies varied by geographic location and area-level socio-economic position. Conclusion: Multiple typologies with contrasting access and healthiness measures exist within Melbourne and these continue to change over time, and the majority of SA2s were dominated by the presence of unhealthy relative to healthy outlets, with SA2s experiencing growth and disadvantage having the lowest access and to a greater proportion of unhealthy outlets. [ABSTRACT FROM AUTHOR]

Background: Environments within schools including the physical, social-cultural and policy/practice environments have the potential to influence children's physical activity (PA) behaviours and weight status. This Australian first study comprehensively examined the association(s) of physical, social-cultural and policy/practice environments with PA, active transport (AT) and weight status among regional primary school children. Methods: Data were from two childhood obesity monitoring systems in regional Victoria, Australia. Measured height and weight were collected from students in Year 2 (aged approx. 7–8 years), Year 4 (9–10 years), and Year 6 (11–12 years). Self–reported PA behaviour, including AT were collected from students in Year 4 and 6 and a sub-sample wore an ActiGraph (wGT3X-BT) accelerometer for 7-days. A school physical activity environment audit was completed by the school principal and responses were used to calculate school physical activity environment scores (PAES) and active transport environment scores (ATES). Mixed effects logistic regression was used to assess the relationship between the proportion of students meeting the PA guidelines (≥60mins/day of moderate-to-vigorous PA) and PAES tertiles (low, medium, high) and those using AT and school ATES tertiles, controlling for gender, school size/type and socioeconomic composition. Results: The analysed sample included 54/146 (37%) schools and 3360/5376 (64%) students. In stratified analysis, girls in schools with a medium PAES score were more likely to meet the objectively measured PA guideline compared to low PAES score (OR 2.3, 95%CI 1.27, 4.16). Similarly, students in schools with a medium or high ATES score had higher odds of self-reported AT (medium OR 3.15, 95%CI 1.67, 5.94; high OR 3.71, 95%CI: 1.80, 7.64). No association between PAES or ATES and weight status were observed. Self-reported AT among boys (OR 1.59, 95%CI 1.19, 2.13) and girls (OR 1.56, 95%CI 1.08, 2.27) was associated with higher odds of meeting self-reported PA guidelines on all 7-days than those who did not report using AT. Conclusions: In this study of regional Victorian primary schools, PA environments were only associated with girls' adherence to PA guidelines. School AT environments were strongly associated with students' AT behaviours and with increased likelihood of students being physically active. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to test the effectiveness of the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS Childhood Obesity) for behavioral, health-related quality of life (HRQoL), and BMI outcomes.Methods: This was a cluster randomized trial of 10 communities randomly allocated (1:1) to start intervention in 2015 (step 1) or in 2019 (after 4 years) in South West Victoria, Australia. Data were collected from participating primary schools in April to June of 2015 (73% school participation rate), 2017 (69%), and 2019 (63%). Student participation rates were 80% in 2015 (1,792/2,516 invited), 81% in 2017 (2,411/2,963), and 79% in 2019 (2,177/2,720). Repeat cross-sectional analyses of measured height and weight (grades two, four, and six [aged approximately 7 to 12 years]), self-reported behavior, and HRQoL (grades four and six) were conducted.Results: There was an intervention by time interaction in BMI z scores (P = 0.031) and obesity/overweight prevalence (P = 0.006). BMI z score and overweight/obesity prevalence decreased between 2015 and 2017 and increased between 2017 and 2019 in intervention communities. The intervention significantly reduced takeaway food consumption (P = 0.034) and improved physical (P = 0.019), psychosocial (P = 0.026), and global (P = 0.012) HRQoL. Water consumption increased among girls (P = 0.033) in the intervention communities, as did energy-dense, nutrient-poor snack consumption among boys (P = 0.006).Conclusions: WHO STOPS had a positive impact on takeaway food intake and HRQoL. [ABSTRACT FROM AUTHOR]

Background: SEA Change Portland is a systems-based approach implemented in Portland, Victoria that utilises local community resources to sustainably prevent and reduce the prevalence of childhood obesity. Action is implemented by community-led task teams with differing priority areas, and supported by a steering committee representative of four collaborating organisations. This study examines the SEA Change Portland process to identify significant events, enablers and barriers of its development and implementation to date as reported by key stakeholders involved in implementation during the first 12 months.Methods: Semi-structured interviews were conducted with eight steering group members and three community task team members. Data was collected utilising open ended interview questions to gather in-depth information regarding program implementation, and the individual attitudes, beliefs and experiences of key stakeholders.Results: Data were analysed under three key themes: collective impact, systems thinking and asset based community development (ABCD). Participants gave perceptions of significant events; factors positively and negatively affecting the process; reasons for becoming involved in the process; perceived efficacy of task teams, principles of diversity and areas of concern. Themes emerged from participant responses allowing were categorisation of their responses into four key process stages: initial lead up; process development; establishing community ownership of the obesity system; and community action.Conclusion: Collective impact was a crucial element in applying the systems thinking. Strong and equitable relationships between steering organisations and topic experts provided the initiative with a sustainable foundation, and ABCD promotes community ownership and future sustainability. Understanding the process of implementing a new whole-of-community systems approach to childhood obesity prevention such as SEA Change Portland has provided vital knowledge for other communities regarding enablers and barriers of this promising approach. [ABSTRACT FROM AUTHOR]

Background: In developed economies, obesity prevalence is high within children from some culturally and linguistically diverse (CALD) backgrounds. This study aims to identify whether CALD groups in Victoria, Australia, are at increased risk of childhood overweight and obesity, and obesity-related dietary behaviours; compared to their non-CALD counterparts.Methods: Objective anthropometric and self-report dietary behavioural data were collected from 2407 Grade 4 and 6 primary school children (aged 9-12 years). Children were categorised into CALD and non-CALD cultural groups according to the Australian Standard Classification of Languages. Overweight/obesity was defined according to the World Health Organization growth reference standards. Obesity-related dietary behaviour categories included excess consumption of takeaway foods, energy-dense, nutrient-poor snacks and sugar sweetened beverages. T-tests and chi-square tests were performed to identify differences in weight status and dietary behaviours between CALD and non-CALD children. Logistic regression analyses examined the relationship between CALD background, weight status and dietary behaviours.Results: Middle-Eastern children had a higher overweight/obesity prevalence (53.0%) than non-CALD children (36.7%; p < 0.001). A higher proportion of Middle-Eastern children had excess consumption of takeaway foods (54.9%), energy-dense, nutrient-poor snacks (36.6%) and sugar sweetened beverages (35.4%) compared to non-CALD children (40.4, 27.0 and 25.0%, respectively; p < 0.05). Southeast Asian and African children were 1.58 (95% CI = [1.06, 2.35]) and 1.61 (95% CI = [1.17, 2.21]) times more likely, respectively, to consume takeaway foods at least once per week than non-CALD children.Conclusions: Disparities in overweight/obesity prevalence and obesity-related dietary behaviours among children in Victoria suggest the need for cultural-specific, tailored prevention and intervention strategies. [ABSTRACT FROM AUTHOR]

Objective: Successful whole-of-community childhood obesity prevention interventions tend to involve community stakeholders in spreading knowledge about and engagement with obesity prevention efforts through the community. This process is referred to by the authors as stakeholder-driven community diffusion (SDCD). This study uses an agent-based model in conjunction with intervention data to increase understanding of how SDCD operates.Methods: This agent-based model retrospectively simulated SDCD during Romp & Chomp, a 4-year whole-of-community childhood obesity prevention intervention in Victoria, Australia. Stakeholder survey data, intervention records, and expert estimates were used to parameterize the model. Model output was evaluated against criteria derived from empirical data and experts' estimates of the magnitude and timing of community knowledge and engagement change.Results: The model was able to produce outputs that met the evaluation criteria: increases in simulated community knowledge and engagement driven by SDCD closely matched expert estimates of magnitude and timing.Conclusions: Strong suggestive evidence was found in support of a hypothesis that SDCD was a key driver of the success of the Romp & Chomp intervention. Model exploration also provided additional insights about these processes (including where additional data collection might prove most beneficial), as well as implications for the design and implementation of future interventions. [ABSTRACT FROM AUTHOR]

Background: Rural Australian populations experience an increased burden of ischaemic heart disease (IHD) compared to their metropolitan counterparts, similar to other developed countries, globally. Policy and other efforts need to address and acknowledge these differences in order to reduce inequalities in health burden. This paper examines rural health policy makers’ perceptions and use of evidence in efforts to reduce the burden of IHD in rural areas. Methods: Policy makers and government advisors (n = 21) who worked with, or advised on, rural health policy at local, state and federal government levels, with specific focus on the state of Victoria (n = 9) were identified from publicly available documents and subsequent snowball sample. Semi-structured qualitative interviews were conducted in regards to the use of evidence in policy to prevent IHD and thematic analysis undertaken applying two theoretical perspectives: context-based evidence-based policy making and the conceptual framework for understanding rural and remote health. Results: The rural context, particularly low resourcing, was seen as limiting potential for evidence based policy at local government (LG) level. Lower levels of political pressure and education were seen as constraints to evidence-based policy in rural communities. Participants described the potential for policy to have a greater impact on reducing heart disease in rural areas though they felt under-resourced and out of touch with the scientific evidence. Scientific studies were less valued than local anecdote to prioritise specific policy. At all levels (local, state and federal) low self-efficacy in interpreting evidence and perceived lack of relevance inhibited development of evidence informed policy. Conclusion: The rural context constrains the use of scientific evidence in policy making for the prevention of heart disease in rural areas in Australia with multiple factors influencing the capacity for evidenced based health policy. This is similar to findings at the international scale and is for consideration across other developed countries that experience inequalities in IHD disease burden between rural and urban populations. [ABSTRACT FROM AUTHOR]

Objective This study examines the relationship between diet quality and health-related quality of life ( HRQoL) in rural and urban Australian adolescents, and gender differences. Design Cross-sectional. Setting Secondary schools. Participants 722 rural and 422 urban students from 19 secondary schools. Main outcome measures Self-report dietary-related behaviours, demographic information, HRQoL ( AQoL-6D) were collected. Healthy and unhealthy diet quality scores were calculated; multiple linear regression investigated associations between diet quality and HRQoL. Results Compared to urban students, rural students had higher HRQoL, higher healthy diet score, lower unhealthy diet score, consumed less soft drink and less frequently, less takeaway and a higher proportion consumed breakfast (P < 0.05). Overall, males had higher unhealthy diet score, poorer dietary behaviours but a higher HRQoL score compared to females (P < 0.05). In all students, final regression models indicated: a unit increase in healthy diet score was associated with an increase in HRQoL (unstandardised coefficient(B)±standard error( SE); B = 0.02 ± 0.01( SE); P < 0.02); and a unit increase in unhealthy diet scores was associated with a decrease in HRQoL (−0.01 ± 0.00; P < 0.05). In rural students alone, a unit increase in unhealthy diet score was associated with a decrease in HRQoL (B = −0.01 ± 0.00; P = 0.002), and in urban students a unit increase in healthy diet score was associated with an increase in HRQoL (B = 0.02 ± 0.00; P < 0.001). Conclusions Cross-sectional associations between diet quality and HRQoL were observed. Dietary modification may offer a target to improve HRQoL and general well-being; and consequently the prevention and treatment of adolescent health problems. Such interventions should consider gender and locality. [ABSTRACT FROM AUTHOR]

Background: Insufficient sleep is potentially an important modifiable risk factor for obesity and poor physical activity and sedentary behaviours among children. However, inconsistencies across studies highlight the need for more objective measures. This paper examines the relationship between sleep duration and objectively measured physical activity, sedentary time and weight status, among a sample of Victorian Primary School children.Methods: A sub-sample of 298 grades four (n = 157) and six (n = 132) Victorian primary school children (aged 9.2-13.2 years) with complete accelerometry and anthropometry data, from 39 schools, were taken from a pilot study of a larger state based cluster randomized control trial in 2013. Data comprised: researcher measured height and weight; accelerometry derived physical activity and sedentary time; and self-reported sleep duration and hypothesised confounding factors (e.g. age, gender and environmental factors).Results: Compared with sufficient sleepers (67 %), those with insufficient sleep (<10 hrs/day) were significantly more likely to be overweight (OR 1.97, 95 % CI:1.11-3.48) or obese (OR 2.43, 95 % CI:1.26-4.71). No association between sleep and objectively measured physical activity levels or sedentary time was found.Conclusion: The strong positive relationship between weight status and sleep deprivation merits further research though PA and sedentary time do not seem to be involved in the relationship. Strategies to improve sleep duration may help obesity prevention initiatives in the future. [ABSTRACT FROM AUTHOR]

Background: There is little empirical evidence of the impact of transition from primary to secondary school on obesity-related risk behaviour. The purpose of this study was to examine the effect of a change of school system on physical activity (PA) and sedentary behaviour in pre-early adolescents. Methods: Fifteen schools in Victoria, Australia were recruited at random from the bottom two strata of a five level socio-economic scale. In nine schools, students in year 6 primary school transitioned to a different school for year 7 secondary school, while in six schools (combined primary-secondary), students remained in the same school environment from year 6 to year 7. Time 1 (T1) measures were collected from students (N=245) in year 6 (age 11-13). Time 2 (T2) data were collected from 243 (99%) of the original student cohort when in year 7. PA and sedentary behaviour data were collected objectively (via ActiGraph accelerometer) and subjectively (via child self-report recall questionnaire). School environment data were collected via school staff survey. Change of behaviour analyses were conducted longitudinally i) for all students and ii) by change/no change of school. Mixed model regression analysis tested for behavioural interaction effects of changing/not changing school. Results: Sixty-three percent (N=152) changed schools from T1 to T2. Across all students we observed declines in average daily moderate to vigorous physical activity (MVPA) (-4 min) and light PA (-23 min), and increases in average daily sedentary behaviour (16 min), weekday leisure screen time (17 min) and weekday homework screen time (25 min), all P<0.05. Compared to students who remained in the same school environment, students who changed school reported a greater reduction in PA intensity at recess and lunch, less likelihood to cycle to/from school, greater increase in weekday (41 mins) and weekend (45 mins) leisure screen time (P<0.05) and greater encouragement to participate in sport. School staff surveys identified that sport participation encouragement was greater in primary and combined primary-secondary than secondary schools (P<0.05). Conclusion: Transitioning from primary to secondary school negatively impacts on children's PA and sedentary behaviour, and has further compounding effects on behaviour type by changing school environments. [ABSTRACT FROM AUTHOR]

The objective is to identify and test regulatory options for creating supportive environments for physical activity and healthy eating among local governments in Victoria, Australia. A literature review identified nine potential areas for policy intervention at local government level, including the walking environment and food policy. Discussion documents were drafted which summarized the public health evidence and legal framework for change in each area. Levels of support for particular interventions were identified through semi-structured interviews conducted with key informants from local government. We conducted 11 key informant interviews and found support for policy intervention to create environments supportive of physical activity but little support for policy changes to promote healthy eating. Participants reported lack of relevance and competing priorities as reasons for not supporting particular interventions. Promoting healthy eating environments was not considered a priority for local government above food safety. There is a real opportunity for action to prevent obesity at local government level (e.g. mandate the promotion of healthy eating environments). For local government to have a role in the promotion of healthy food environments, regulatory change and suitable funding are required. [ABSTRACT FROM AUTHOR]

Background: Community-based interventions have shown promise in addressing the childhood obesity epidemic. Such efforts rely on the knowledge of key community members and their engagement with the drivers of obesity in their community. This paper presents the protocol for the measurement and evaluation of knowledge and engagement among community leaders within a whole-of-community systems intervention across 10 large intervention communities in Australia.Methods: We will investigate the role of stakeholder knowledge and engagement in the implementation and effectiveness of the stepped wedge cluster randomised trial in ten communities in Victoria, Australia. Data will be collected using the Stakeholder-driven Community Diffusion Survey (SDCD) to measure levels of knowledge and engagement prior to commencement (2019), across the three separate levels of governance within the intervention at five time points. Primary outcomes will be baseline overall knowledge and engagement scores across the three levels of governance and change in overall knowledge and engagement over time.Discussion: We hypothesise there will be heterogeneity between intervention sites on levels of knowledge and engagement and that these differences will be associated with variability in implementation success.Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618001986268 . Registered on 11 December 2018. [ABSTRACT FROM AUTHOR]

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

• FoodPATH used group model building tocollaborate with Aboriginal organisations around food policy. • Workshops with six ACCOs revealed feedback loops across nine themes. • The issues of junk food marketing, food affordability, nutrition in schools and food knowledge and skills were key issues across all sites. • Group model building enabled Community-driven recommendations for system-wide actions to improve food environments. First Nations peoples have the right to participate in all decisions affecting them. This includes food policy decision-making. In the Australian state of Victoria, the Food Policies for Aboriginal and Torres Strait Islander Health (FoodPATH) project aimed to determine the food policy actions that are likely to be effective and acceptable for Victorian Aboriginal Communities. Community-based workshops were held with six Aboriginal Community-Controlled Organisations (ACCOs) in urban and regional Victoria during 2022. A team of at least three Aboriginal and Torres Strait Islander facilitators guided participants (n = 53) through a series of workshop activities using group model building methods. Group model building is a participatory systems science research method which enables community stakeholders to develop a shared understanding of the system-level drivers of complex problems and co-design actions to address them. Workshop discussions coincided with real-time creation of a visual system map of the interconnected determinants of food choice. Participants used these maps to develop and prioritise actions for improving food environments and nutrition in the community. Participants identified a diverse array of interconnected factors influencing food choice and nutrition in Aboriginal Communities across Victoria. Food access and affordability, junk food marketing, food knowledge and skills and diet and disease were common themes across all sites, while access to junk food, growing local food, traditional Aboriginal foods, and family, Community and culture were key themes in most sites. Results informed a Community-driven agenda, comprising five Community-led actions and five government policy recommendations for improving food environments and nutrition for Victorian Aboriginal Communities. [ABSTRACT FROM AUTHOR]

Background: Over a quarter of children aged 2-17 years living in Australia are overweight or obese, with a higher prevalence reported in regional and remote communities. Systems thinking approaches that seek to support communities to generate and implement locally appropriate solutions targeting intertwined environmental, political, sociocultural, and individual determinants of obesity have the potential to ameliorate this. There have however been reported challenges with implementation of such initiatives, which may be strengthened by incorporating implementation science methods., Methods: This pilot randomised controlled trial protocol outlines the development and proposed evaluation of a multicomponent implementation strategy (Action-RESPOND). to increase the implementation of community-based systems thinking child obesity prevention initiatives The target of this intervention is ten rural and regional communities (or local government areas as the unit of allocation) within Northeast Victoria who were participants in a whole-of-systems intervention (RESPOND). Action-RESPOND builds on this intervention by assessing the impact of offering additional implementation strategies to five communities relative to usual care. The development of the multicomponent implementation strategy was informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework and consists of seven implementation strategies primarily delivered via 'facilitation' methods. Implementation strategies aimed to ensure initiatives implemented are i) evidence-based, ii) address community's specific needs and iii) are suitable for local context. Strategies also aimed to increase the community's capacity to implement, through iv) improving the health promotion team's implementation knowledge and skills, fostering v) leadership, vi) physical resources and vii) community culture to drive implementation. The feasibility, acceptability, potential impact, and cost of the strategy will be assessed at baseline and follow up using surveys administered to key representatives within the community and internal records maintained by the research team., Discussion: By leveraging an existing community-based whole-of-systems intervention, Action-RESPOND offers a unique opportunity to collect pilot feasibility and early empirical data on how to apply implementation and systems science approaches to support obesity prevention in rural and regional communities in Victoria., Competing Interests: S.A. is a co-inventor of the STICKE software, which is used in this study. All other authors have no conflict of interest to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Yoong et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Research into the co-creation of healthy food retail is in its early stages. One way to advance co-creation research is to explore and understand how co-creation was applied in developing, implementing, and evaluating a heath-enabling initiative in a supermarket in regional Victoria, Australia. A case study design was used to explore and understand how co-creation was applied in the Eat Well, Feel Good Ballarat project. Six documents and reports related to the Eat Well, Feel Good Ballarat project were analyzed with findings from the focus groups and interviews. Motivations to develop or implement health-enabling supermarket initiatives differed among the participants. Participants considered that initial negotiations were insufficient to keep the momentum going and to propose the value to the retailers to scale up the project. Presenting community-identified needs to the supermarket helped gain the retailer's attention, whilst the co-design process helped the implementation. Showcasing the project to the community through media exposure kept the supermarket interested. Retailers' time constraints and staff turnover were considered significant barriers to partnership building. This case study contributes insights into applying co-creation to health-enabling strategies in food retail outlets using two co-creation frameworks.

Objective: To present an approach to build capacity for the use of systems science to support local communities in municipal public health and well-being planning., Design: Case study., Setting: Local government authorities participating in the VicHealth Local Government Partnership in Victoria, Australia., Participants: Local government staff members were trained in community-based system dynamics (CBSD), and group model building (GMB) techniques to mobilise local community efforts. The trained local government facilitation teams then delivered GMB workshops to community stakeholder groups from 13 local government areas (LGA)s., Main Outcomes: Training in CBSD was conducted with council facilitation teams in 13 LGAs, followed by the local delivery of GMB workshops 1-3 to community stakeholders. Causal loop diagrams (CLD) representing localised drivers of mental well-being, healthy eating, active living or general health and well-being of children and young people were developed by community stakeholders. Locally tailored action ideas were generated such as well-being classes in school, faster active transport and access to free and low-cost sporting programmes RESULTS: Overall, 111 local government staff participated in CBSD training. Thirteen CLDs were developed, with the stakeholders that included children, young people and community members, who had participated in the GMB workshops across all 13 council sites. Workshop 3 had the highest total number of participants (n=301), followed by workshop 1 (n=287) and workshop 2 (n=171)., Conclusions: Local facilitation of the CBSD process has developed community informed and locally relevant CLDs that will be used to lead local action to improve the well-being of children and young people. Training employees in CBSD is one approach to increase systems thinking capacity within local government., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Systems science methodologies have been used in attempts to address the complex and dynamic causes of childhood obesity with varied results. This paper presents a protocol for the Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND) trial. RESPOND represents a significant advance on previous approaches by identifying and operationalising a clear systems methodology and building skills and knowledge in the design and implementation of this approach among community stakeholders., Methods and Analysis: RESPOND is a 4-year cluster-randomised stepped-wedge trial in 10 local government areas in Victoria, Australia. The intervention comprises four stages: catalyse and set up, monitoring, community engagement and implementation. The trial will be evaluated for individuals, community settings and context, cost-effectiveness, and systems and implementation processes. Individual-level data including weight status, diet and activity behaviours will be collected every 2 years from school children in grades 2, 4 and 6 using an opt-out consent process. Community-level data will include knowledge and engagement, collaboration networks, economic costs and shifts in mental models aligned with systems training. Baseline prevalence data were collected between March and June 2019 among >3700 children from 91 primary schools., Ethics and Dissemination: Ethics approval: Deakin University Human Research Ethics Committee (HREC 2018-381) or Deakin University's Faculty of Health Ethics Advisory Committee (HEAG-H&#95;2019-1; HEAG-H 37&#95;2019; HEAG-H 173&#95;2018; HEAG-H 12&#95;2019); Victorian Government Department of Education and Training (2019&#95;003943); Catholic Archdiocese of Melbourne (Catholic Education Melbourne, 2019-0872) and Diocese of Sandhurst (24 May 2019). The results of RESPOND, including primary and secondary outcomes, and emerging studies developed throughout the intervention, will be published in the academic literature, presented at national and international conferences, community newsletters, newspapers, infographics and relevant social media., Trial Registration Number: ACTRN12618001986268p., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Approximately a quarter of Australian children are classified as overweight or obese. In high-income countries, childhood obesity follows a socio-economic gradient, with greater prevalence amongst the most socio-economically disadvantaged children. Community-based interventions (CBI), particularly those using a systems approach, have been shown to be effective on weight and weight-related behaviours. They are also thought to have an equitable impacts, however there is limited evidence of their effectiveness in achieving this goal., Methods: Secondary analysis was conducted on data collected from primary school children (aged 6-13 years) residing in ten communities (five intervention, five control) involved in the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS) cluster randomised trial in Victoria, Australia. Outcomes included Body Mass Index z-score (BMI-z) derived from measured height and weight, self-reported physical activity and dietary behaviours and health related quality of life (HRQoL). Repeat cross-sectional data from 2015 (n = 1790) and 2019 (n = 2137) were analysed, stratified by high or low socio-economic position (SEP). Multilevel linear models and generalised estimating equations were fitted to assess whether SEP modified the intervention effect on the outcomes., Results: There were no overall changes in BMI-z for either SEP strata. For behavioural outcomes, the intervention resulted in a 22.5% (95% CI 5.1, 39.9) point greater improvement in high-SEP compared to low-SEP intervention schools for meeting physical activity guidelines. There were also positive dietary intervention effects for high SEP students, reducing takeaway and packaged snack consumption, although there was no significant difference in effect between high and low SEP students. There were positive intervention effects for HRQoL, whereby scores declined in control communities with no change in intervention communities, and this did not differ by SEP., Conclusion: The WHO STOPS intervention had differential effects on several weight-related behaviours according to SEP, including physical activity. Similar impacts on HRQoL outcomes were found between high and low SEP groups. Importantly, the trial evaluation was not powered to detect subgroup differences. Future evaluations of CBIs should be designed with an equity lens, to understand if and how these types of interventions can benefit all community members, regardless of their social and economic resources., (© 2021. The Author(s).)

Objectives: To explore whether the physical activity (PA) environment (walkability, greenspace and recreational facilities) surrounding regional primary schools is associated with children's PA levels, active transport and weight status. Limited research on this topic has been conducted outside of major cities., Design: Cross-sectional ecological study using baseline data from two large-scale obesity prevention interventions., Setting: Eighty (n=80) primary schools across two regional areas in Victoria, Australia., Participants: Students aged 8-13 years (n=2144) attending participating primary schools., Outcome Measures: Measured weight status (body mass index z-score, proportion overweight/obese) and self-reported PA behaviours (meeting PA recommendations and active travel behaviour)., Results: When adjusted for student and school demographics, students had significantly increased odds of using active transport to or from school when the school neighbourhood was more walkable (OR 1.21 (95% CI 1.09 to 1.35), had a greater number of greenspaces (OR 1.35 (95% CI 1.20 to 1.53)) and a greater number of recreational facilities (OR 1.18 (95% CI 1.07 to 1.31)). A higher cumulative PA environment score was also associated with a higher proportion of children using active transport (OR 1.33 (95% CI 1.28 to 1.51)). There were no significant associations between the PA environment measures and either weight status or meeting the PA recommendations in adjusted models., Conclusions: This study is the first of its kind exploring school neighbourhood environments and child weight status and PA in regional areas of Australia. It highlights the potential of the environment surrounding primary schools in contributing to students' active travel to and from school. Further research with the use of objective PA measurement is warranted in regional areas that have been under-researched., Trial Registration Number: Australian New Zealand Clinical Trials Registry (ANZCTR.org.au) identifier 12616000980437; Results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Early childhood overweight and obesity increased substantially in high-income countries throughout the 1980s and 1990s. The flattening or reversal of this trend since the early 2000s might conceal widening inequalities. This study aimed to identify trends in body-mass index Z score (BMIz) among children aged 1-3·5 years in Victoria (Australia), by socioeconomic status and geographical location., Methods: This repeated, cross-sectional study used deidentified records of height, weight, and demographic information from electronic databases in the Victorian Maternal and Child Health system. Data from the consultations for children aged 1, 2, and 3·5 years were included in this analysis. We removed duplicate records; records with missing data for sex, age, weight, height, or postcode; and records with postcodes that were outside of Victoria. The coprimary outcomes were trends in mean BMIz (continuous linear models) and prevalence of high BMIz (>+1; generalised linear models), estimated for six independent age-sex groups. Secondary analysis was done for the prevalence of BMIz greater than 2. Effect modification by socioeconomic status and remoteness was evaluated., Findings: Electronic data were available for 48 local government areas collected between Jan 1, 2003, and Dec 31, 2017, representing approximately 63% of the Victorian population. Overall, 1 329 520 measurements from 675 991 children were included in the analysis. There were small, significantly decreasing trends in mean BMIz across all six age-sex groups, overall and in major cities. Similar patterns were observed for some subgroups in prevalence of high BMIz. These decreasing trends appear to be partly explained by migration. Conversely, in regional areas the trends in BMIz were consistently increasing in all age-sex groups and across socioeconomic strata, although not all groups were statistically significant. Inequalities in BMIz according to socioeconomic status persisted throughout the study period, such that the children from more advantaged areas had lower mean BMIz., Interpretation: This study showed that at a state level, mean BMIz and prevalence of high BMIz decreased in children aged 1, 2, and 3·5 years in Victoria between 2003 and 2017. We found metropolitan-regional differences to be key source of inequality in early childhood BMIz trends, alongside area-level socioeconomic status. These findings highlight the risk that analysis of overall trends in childhood BMIz might obscure important inequalities according to, for example, remoteness, socioeconomic status, and ethnicity. Future research requires monitoring data with large population samples to adequately examine differences in prevalence and trends between population subgroups., Funding: None., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Understanding levels of community readiness can result in prevention efforts that align with communities' ability and capacity for change and, therefore, be more effective and sustainable. Our study aimed to use baseline (pre-intervention) community readiness scores to assist with the development of obesity prevention strategies, and to assess changes in community readiness over time (pre/post- intervention), to provide evidence of intervention impact., Method: Our study was located in a rural and remote area of Victoria, Australia. Community readiness was part of a broader obesity prevention intervention designed to create healthier food and physical activity environments through the combination of systems thinking and collaborative community-led solutions. Interviews were conducted using the community readiness to change tool in 2016 (pre) and 2018 (post) with a community representative sample. Baseline data informed the development of community relevant strategies and the pre/post results formed part of the overall evaluation., Results: The tool generated both quantitative and qualitative (quotes) data. A final readiness score was calculated that corresponded to one of the nine stages of readiness. Four of the five domains of the community readiness to change tool showed statistically significant improvements over time (p < 0.05): knowledge of effort, knowledge of issue, community climate, and leadership. The resources domain that did not improve pre/post intervention., Conclusion: Community readiness to change interviews, pre- and post- intervention, provided essential information related to the appropriate targeting and pitch of the prevention strategies, as well as providing an overall evaluation of the positive movement in the community's readiness to implement change.

(1) Background: Childhood overweight and obesity is a significant and preventable problem worldwide. School environments have been suggested to be plausible targets for interventions seeking to improve the quality of children's dietary intake. The objective of this study was to determine the extent to which the current characteristics of the school food environment were associated with primary school students' dietary intake and Body Mass Index (BMI) z scores in a representative sample in regional Victoria. (2) Methods: This study included 53 schools, comprising a sample of 3,496 students in year levels two (aged 7-8 years), four (9-10 years) and six (11-12 years). Year four and six students completed dietary questionnaires. Principals from each school completed a survey on school food environment characteristics. Mixed-effects logistic regression was used to assess the relationship between students' dietary intake and school food environment scores, controlling for confounders such as socio-economic status, school size and sex. Food environment scores were also analysed against the odds of being healthy weight (defined as normal BMI z score). (3) Results: Mixed associations were found for the relationship between students' dietary intake and food environment scores. Meeting the guidelines for vegetable intake was not associated with food environment scores, but students were more likely (OR: 1.68 95% CI 1.26, 2.24) to meet the guidelines if they attended a large school (>300 enrolments) and were female (OR: 1.28 95% CI: 1.02, 1.59). Healthy weight was not associated with school food environment scores, but being a healthy weight was significantly associated with less disadvantage (OR: 1.24 95% CI 1.05, 1.45). Conclusion: In this study, the measured characteristics of school food environments did not have strong associations with dietary intakes or BMI among students.

Issue Addressed: Schools are a target for childhood obesity prevention strategies, yet intervention effectiveness may be hindered by school community perceptions (staff and students) and readiness to address the problem. We firstly describe students' perception of their own weight status. Secondly, we describe school staff perceptions and preparedness to address childhood obesity in their school., Methods: Measured and self-report weight status were collected simultaneously from 11- to 14-year-old students (N = 339/733; RR 46%) recruited from 42 schools in Victoria, Australia. Student objective weight status was compared to self-report. School community readiness to address childhood obesity data was collected from staff (N = 114) at all participating schools. School readiness survey data were scored and descriptive analyses conducted for further insight of derived readiness scores., Results: Using objective assessment, 18% (n = 62) of students were obese, but only 4% (n = 12) accurately identified themselves as obese. School communities were concerned about the problem of childhood obesity in general, yet were assessed at low stages of readiness to take action within their community. Descriptive data identified a strong focus on promoting healthy eating and physical activity through education. Further efforts to target childhood obesity appeared to be hindered by limited support, resources and engagement with the broader community., Conclusion: Perceptions of childhood obesity prevalence, low stages of readiness and limited school capacity may hinder prevention strategies. SO WHAT?: Perceptions of what is normal weight may have implications for prevention. Efforts must be informed by accurate weight data and require a broader community approach beyond the school environment., (© 2018 Australian Health Promotion Association.)

Background: Involving groups of community stakeholders (e.g., steering committees) to lead community-wide health interventions appears to support multiple outcomes ranging from policy and systems change to individual biology. While numerous tools are available to measure stakeholder characteristics, many lack detail on reliability and validity, are not context specific, and may not be sensitive enough to capture change over time. This study describes the development and reliability of a novel survey to measure Stakeholder-driven Community Diffusion via assessment of stakeholders' social networks, knowledge, and engagement about childhood obesity prevention., Methods: This study was completed in three phases. Phase 1 included conceptualization and online survey development through literature reviews and expert input. Phase 2 included a retrospective study with stakeholders from two completed whole-of-community interventions. Between May-October 2015, 21 stakeholders from the Shape Up Somerville and Romp & Chomp interventions recalled their social networks, knowledge, and engagement pre-post intervention. We also assessed one-week test-retest reliability of knowledge and engagement survey modules among Shape Up Somerville respondents. Phase 3 included survey modifications and a second prospective reliability assessment. Test-retest reliability was assessed in May 2016 among 13 stakeholders involved in ongoing interventions in Victoria, Australia., Results: In Phase 1, we developed a survey with 7, 20 and 50 items for the social networks, knowledge, and engagement survey modules, respectively. In the Phase 2 retrospective study, Shape Up Somerville and Romp & Chomp networks included 99 and 54 individuals. Pre-post Shape Up Somerville and Romp & Chomp mean knowledge scores increased by 3.5 points (95% CI: 0.35-6.72) and (- 0.42-7.42). Engagement scores did not change significantly (Shape Up Somerville: 1.1 points (- 0.55-2.73); Romp & Chomp: 0.7 points (- 0.43-1.73)). Intraclass correlation coefficients (ICCs) for knowledge and engagement were 0.88 (0.67-0.97) and 0.97 (0.89-0.99). In Phase 3, the modified knowledge and engagement survey modules included 18 and 25 items, respectively. Knowledge and engagement ICCs were 0.84 (0.62-0.95) and 0.58 (0.23-0.86)., Conclusions: The survey measures upstream stakeholder properties-social networks, knowledge, and engagement-with good test-retest reliability. Future research related to Stakeholder-driven Community Diffusion should focus on prospective change and survey validation for intervention effectiveness.

Introduction: Prevention of overweight and obesity in childhood is a priority because of associated acute and chronic conditions in childhood and later in life, which place significant burden on health systems. Evidence suggests prevention should engage a range of actions and actors and target multiple levels. The Whole of Systems Trial Of Prevention S trategies for childhood obesity (WHO STOPS) will evaluate the outcomes of a novel systems-based intervention that aims to engage whole communities in a locally led multifaceted response. This paper describes the planned economic evaluation of WHO STOPS and examines the methodological challenges for economic evaluation of a complex systems-based intervention., Methods and Analysis: Economic evaluation alongside a stepped-wedge cluster randomised controlled trial in regional and rural communities in Victoria, Australia. Cost-effectiveness and cost-utility analyses will provide estimates of the incremental cost (in $A) per body mass index unit saved and quality adjusted life year gained. A Markov cohort model will be employed to estimate healthcare cost savings and benefits over the life course of children. The dollar value of community resources harnessed for the community-led response will be estimated. Probabilistic uncertainty analyses will be undertaken to test sensitivity of results to plausible variations in all trial-based and modelled variables. WHO STOPS will also be assessed against other implementation considerations (such as sustainability and acceptability to communities and other stakeholders)., Ethics and Dissemination: The trial is registered by the Australian New Zealand Clinical Trials Registry (ACTRN12616000980437). Full ethics clearances have been received for all methods described below: Deakin University's Human Research Ethics Committee 2014-279, Deakin University's Human Ethics Advisory Group-Health (HEAG-H) HEAG-H 194&#95;2014, HEAG-H 17 2015, HEAG-H 155&#95;2014, HEAG-H 197&#95;2016, HEAG-H 118&#95;2017, the Victorian Department of Education and Training 2015&#95;002622 and the Catholic Archdiocese of Ballarat. Trial findings (including economic evaluation) will be published in peer-reviewed journals and presented at international conferences. Collected data and analyses will be made available in accordance with journal policies and study ethics approvals. Results will be presented to relevant government authorities with an interest in cost-effectiveness of these types of interventions., Trial Registration Number: ACTRN12616000980437; Pre-results., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Tracking population trends in childhood obesity and identifying target areas for prevention requires accurate prevalence data. This study quantified the magnitude of non-participation bias for mean Body Mass Index-z scores and overweight/obesity prevalence associated with low (opt-in) compared to high (opt-out) participation consent methodologies. Methods: Data arose from all Local Government Areas (LGAs) participating in the Healthy Together Victoria Childhood Obesity Study, Australia. Primary schools were randomly selected in 2013 and 2014 and all Grades 4 and 6 students (aged approx. 9-12 years) were invited to participate via opt-in consent (2013) and opt-out consent (2014). For the opt-in wave N = 38 schools (recruitment rate (RR) 24.3%) and N = 856 students participated (RR 36.3%). For the opt-out wave N = 47 schools (RR 32%) and N = 2557 students participated (RR 86.4%)., Outcomes: differences between opt-in and opt-out sample estimates (bias) for mean BMI-z, prevalence of overweight/obesity and obesity (alone). Standardized bias (Std bias) estimates defined as bias/standard error are reported for BMI-z. Results : The results demonstrate strong evidence of non-participation bias for mean BMI-z overall (Std bias = -4.5, p < 0.0001) and for girls (Std bias = -5.4, p < 0.0001), but not for boys (Std bias = -1.1, p = 0.15). The opt-in strategy underestimated the overall population prevalence of overweight/obesity and obesity by -5.4 and -4.5 percentage points respectively ( p < 0.001 for both). Significant underestimation was seen in girls, but not for boys. Conclusions: Opt-in consent underestimated prevalence of childhood obesity, particularly in girls. Prevalence, monitoring and community intervention studies on childhood obesity should move to opt-out consent processes for better scientific outcomes., Competing Interests: Authors have no conflicts to disclose.