Professor John Wiggers

Objective: To identify the optimal AUSDRISK threshold score to screen for pre-diabetes and diabetes. Methods: A total of 406 adult patients not diagnosed with diabetes were screened in General Practices (GP) between May and October 2019. All patients received a point of care (POC) HbA1c test. HbA1c test results were categorised into diabetes (=6.5% or =48 mmol/mol), pre-diabetes (5.7¿6.4% or 39¿47 mmol/mol), or normal (<5.7% or 39 mmol/mol). Results: Of these patients, 9 (2%) had undiagnosed diabetes and 60 (15%) had pre-diabetes. A Receiver Operator Characteristic (ROC) curve was constructed to predict the presence of pre-diabetes and diabetes; the area under the ROC curve was 0.72 (95%CI 0.65¿0.78) indicating modest predictive ability. The optimal threshold cut point for AUSDRISK score was 17 (sensitivity 76%, specificity 61%, + likelihood ratio (LR) 1.96, - likelihood ratio of 0.39) while the accepted cut point of 12 performed less well (sensitivity 94%, specificity 23%, +LR=1.22 -LR+0.26). Conclusions: The AUSDRISK tool has the potential to be used as a screening tool for pre-diabetes/diabetes in GP practices. A cut point of =17 would potentially identify 75% of all people at risk and three in 10 sent for further testing would be positive for prediabetes or diabetes. Implications for public health: Routine case-finding in high-risk patients will enable GPs to intervene early and prevent further public health burden from the sequelae of diabetes.

Background: Population health prevention programmes are needed to reduce the prevalence of chronic diseases. Nevertheless, sustaining programmes at a population level is challenging. Population health is highly influenced by social, economic and political environments and is vulnerable to these system-level changes. The aim of this research was to examine the factors and mechanisms contributing to the sustainment of population prevention programmes taking a systems thinking approach. Methods: We conducted a qualitative study through interviews with population health experts working within Australian government and non-government agencies experienced in sustaining public health programs at the local, state or national level (n = 13). We used a deductive thematic approach, grounded in systems thinking to analyse data. Results: We identified four key barriers affecting program sustainment: 1) short term political and funding cycles; 2) competing interests; 3) silo thinking within health service delivery; and 4) the fit of a program to population needs. To overcome these barriers various approaches have centred on the importance of long-range planning and resourcing, flexible program design and management, leadership and partnerships, evidence generation, and system support structures. Conclusion: This study provides key insights for overcoming challenges to the sustainment of population health programmes amidst complex system-wide changes.

Objectives: Assess the impact of an implementation intervention on student's physical activity, health-related quality of life (HRQoL) and on-task behaviour. Design: A cluster-randomised controlled trial. Methods: Following baseline 61 eligible schools were randomised to a 12-month, implementation intervention to increase teacher scheduling of physical activity, or a waitlist control. Whole school-day and class-time physical activity of students from grades 2 and 3 (~ages 7 to 9) were measured via wrist-worn accelerometers and included: moderate-to-vigorous physical activity, light physical activity, sedentary behaviour and activity counts per minute. Children's health related quality of life (HRQoL) and out-of-school-hours physical activity was measured via parent-proxy surveys. Class level on-task behaviour was measured via teacher self-report surveys. Student and teacher obtained outcomes were measured at baseline and 12-month follow-up. Parent reported outcomes were measured at 12-month follow-up. Linear mixed models compared between group differences in outcomes. Differential effects by sex were explored for student and parent reported outcomes. Results: Data from 2485 students, 1220 parents and >500 teachers were analysed. There was no statistically significant between group differences in any of the outcomes, including accelerometer measured physical activity, out-of-school-hours physical activity, HRQoL, and on-task behaviour. A statistically significant differential effect by sex was found for sedentary behaviour across the whole school day (3.16 min, 95% CI: 0.19, 6.13; p = 0.028), with females illustrating a greater difference between groups than males. Conclusions: Only negligible effects on student physical activity were found. Additional strategies including improving the quality of teacher's delivery of physical activity may be required to enhance effects.

Background: Effectively scaled-up physical activity interventions are urgently needed to address the high prevalence of physical inactivity. To facilitate scale-up of an efficacious school-based physical activity program (Physical Activity 4 Everyone [PA4E1]), provision of implementation support to physical education (PE) teachers was adapted from face-to-face and paper-based delivery modes to partial delivery via a website. A lack of engagement (usage and subjective experience) with digital delivery modes, including websites, may in part explain the typical reduction in effectiveness of scaled-up interventions that use digital delivery modes. A process evaluation focused on the PA4E1 website was undertaken. Objective: The 2 objectives were to (1) describe the usage of the PA4E1 program website by in-school champions (PE teachers leading the program within their schools) and PE teachers using quantitative methods; (2) examine the usage, subjective experience, and usability of the PA4E1 program website from the perspective of in-school champions using mixed methods. Methods: The first objective used website usage data collected across all users (n=273) throughout the 9 school terms of the PA4E1 implementation support. The 4 usage measures were sessions, page views, average session duration, and downloads. Descriptive statistics were calculated and explored across the duration of the 26-month program. The second objective used mixed methods, triangulating data from the first objective with data from a think-aloud survey and usability test completed by in-school champions (n=13) at 12 months. Qualitative data were analyzed thematically alongside descriptive statistics from the quantitative data in a triangulation matrix, generating cross-cutting themes using the "following a thread" approach. Results: For the first objective, in-school champions averaged 48.0 sessions per user, PE teachers 5.8 sessions. PE teacher sessions were of longer duration (10.5 vs 7.6 minutes) and included more page views (5.4 vs 3.4). The results from the mixed methods analysis for the second objective found 9 themes and 2 meta-themes. The first meta-theme indicated that the website was an acceptable and appropriate delivery mode, and usability of the website was high. The second meta-theme found that the website content was acceptable and appropriate, and identified specific suggestions for improvement. Conclusions: Digital health interventions targeting physical activity often experience issues of lack of user engagement. By contrast, the findings from both the quantitative and mixed methods analyses indicate high usage and overall acceptability and appropriateness of the PA4E1 website to school teachers. The findings support the value of the website within a multidelivery mode implementation intervention to support schools to implement physical activity promoting practices. The analysis identified suggested intervention refinements, which may be adopted for future iterations and further scale-up of the PA4E1 program.

Background: There is significant opportunity to improve the nutritional quality of foods packed in children's school lunchboxes. Interventions that are effective and scalable targeting the school and home environment are therefore warranted. Objective: This study aimed to assess the effectiveness of a multicomponent, mobile health-based intervention, SWAP IT, in reducing the energy contribution of discretionary (ie, less healthy) foods and drinks packed for children to consume at school. Methods: A type I effectiveness-implementation hybrid cluster randomized controlled trial was conducted in 32 primary schools located across 3 local health districts in New South Wales, Australia, to compare the effects of a 6-month intervention targeting foods packed in children's lunchboxes with those of a usual care control. Primary schools were eligible if they were not participating in other nutrition studies and used the required school communication app. The Behaviour Change Wheel was used to co-design the multicomponent SWAP IT intervention, which consisted of the following: school lunchbox nutrition guidelines, curriculum lessons, information pushed to parents digitally via an existing school communication app, and additional parent resources to address common barriers to packing healthy lunchboxes. The primary outcome, mean energy (kilojoules) content of discretionary lunchbox foods and drinks packed in lunchboxes, was measured via observation using a validated school food checklist at baseline (May 2019) and at 6-month follow-up (October 2019). Additional secondary outcomes included mean lunchbox energy from discretionary foods consumed, mean total lunchbox energy packed and consumed, mean energy content of core lunchbox foods packed and consumed, and percentage of lunchbox energy from discretionary and core foods, all of which were also measured via observation using a validated school food checklist. Measures of school engagement, consumption of discretionary foods outside of school hours, and lunchbox cost were also collected at baseline and at 6-month follow-up. Data were analyzed via hierarchical linear regression models, with controlling for clustering, socioeconomic status, and remoteness. Results: A total of 3022 (3022/7212, 41.90%) students consented to participate in the evaluation (mean age 7.8 years; 1487/3022, 49.22% girls). There were significant reductions between the intervention and control groups in the primary trial outcome, mean energy (kilojoules) content of discretionary foods packed in lunchboxes (-117.26 kJ; 95% CI -195.59 to -39.83; P=.003). Relative to the control, the intervention also significantly reduced secondary outcomes regarding the mean total lunchbox energy (kilojoules) packed (-88.38 kJ; 95% CI -172.84 to -3.92; P=.04) and consumed (-117.17 kJ; 95% CI -233.72 to -0.62; P=.05). There was no significant difference between groups in measures of student engagement, consumption of discretionary foods outside of school hours, or cost of foods packed in children's lunchboxes. Conclusions: The SWAP IT intervention was effective in reducing the energy content of foods packed for and consumed by primary school-aged children at school. Dissemination of the SWAP IT program at a population level has the potential to influence a significant proportion of primary school-aged children, impacting weight status and associated health care costs.

Background: Physical Activity 4 Everyone (PA4E1) is an evidence-based program effective at increasing adolescent physical activity (PA) and improving weight status. This study aimed to determine a) the effectiveness of an adapted implementation intervention to scale-up PA4E1 at 24-month follow-up, b) fidelity and reach, and c) the cost and cost-effectiveness of the implementation support intervention. Methods: A cluster randomised controlled trial using a type III hybrid implementation-effectiveness design in 49 lower socio-economic secondary schools, randomised to a program (n = 24) or control group (n = 25). An adapted implementation intervention consisting of seven strategies was developed to support schools to implement PA4E1 over 24-months. The primary outcome was the proportion of schools implementing at least four of the 7 PA practices, assessed via computer assisted telephone interviews (CATI) with Head Physical Education Teachers. Secondary outcomes included the mean number of PA practices implemented, fidelity and reach, cost and cost-effectiveness. Logistic regression models assessed program effects. Results: At baseline, no schools implemented four of the 7 PA practices. At 24-months, significantly more schools in the program group (16/23, 69.6%) implemented at least four of the 7 PA practices than the control group (0/25, 0%) (p < 0.001). At 24-months, program schools were implementing an average of 3.6 more practices than control schools (4.1 (1.7) vs. 0.5 (0.8), respectively) (P < 0.001). Fidelity and reach of the implementation intervention were high (> 75%). The total cost of the program was $415,112 AUD (2018) ($17,296 per school; $117.30 per student). Conclusions: The adapted implementation intervention provides policy makers and researchers with an effective and potentially cost-effective model for scaling-up the delivery of PA4E1 in secondary schools. Further assessment of sustainability is warranted. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 prospectively registered 12th May 2017.

Uptake of online and telephone services targeting health behaviours is low among vocational education students and barriers and facilitators are unknown. This study aimed to explore barriers and facilitators to uptake of online and telephone services for smoking, nutrition, alcohol, and physical activity (SNAP) risk behaviours via semi-structured individual telephone interviews with fifteen vocational education students. Two authors independently completed thematic analysis, classified themes according to the COM-B (Capability, Opportunity, Motivation, Behaviour) frame-work, and discussed disagreements until consensus was reached. Facilitators to uptake of online (e.g., desire to learn something new, cost-free, accessible) and telephone services (e.g., prefer to talk to provider, complements online support) primarily related to capability and opportunity. For telephone services, difficulty understanding accent/language was a capability-related barrier. Opportunity-related barriers for online and telephone services were preference for face-to-face interaction and lack of time, while preference for apps/online programs was a barrier for telephone services. For online and telephone services, not wanting to change SNAP behaviours was a motivation-related barrier and being able to change SNAP risk behaviours themselves was a motivation-related barrier for online services. Barriers and facilitators to online and telephone services are relevant for designing interventions vocational education students are more likely to use.

People with a mental illness experience a disproportionate burden of chronic disease morbidity and mortality; contributed to by a higher prevalence of health risk behaviours that increase the risk of chronic disease development. Amongst this population there is little understanding of multiple risk behaviour co-occurrence and client interest in improving multiple such risks. A cross-sectional survey was undertaken with a random selection of 557 clients of 12 community mental health services in Australia. Participants reported their engagement in health risk behaviours (tobacco smoking, harmful alcohol consumption, inadequate fruit and/or vegetable consumption, and inadequate physical activity), and those deemed ¿at risk¿ reported whether they were seriously considering improving their risk behaviours. Almost all participants engaged in at least one risk behaviour (96.1%), with 78.4% of participants engaging in two or more risk behaviours. Of those with two risks, the most frequently paired behaviours were inadequate fruit and vegetable consumption and inadequate physical activity (39.7%); of those with three risks the most common combination was inadequate fruit and vegetable consumption, tobacco smoking and harmful alcohol consumption (42.5%). Of those at risk for all behaviours, 68.4% were interested in improving multiple behaviours, and 14% were interested in improving all; with these participants being most frequently interested in changing smoking, nutrition, and physical activity (19.3%), followed by all risk behaviours (14.0%). The findings strengthen the evidence that people with a mental illness are interested in improving their health risk behaviours and indicate a need to address the multiple health risks in this population group.

People living with mental health conditions have a reduced life expectancy of approximately 10 years compared to the general population, largely due to physical chronic diseases and higher rates of tobacco smoking, poor nutrition, harmful alcohol consumption, physical inactivity and poor sleep behaviours. Community managed organisations (CMOs) may play a valuable role in providing preventive care to people with mental health conditions (consumers) to address these health behaviours. This paper reports the findings of a cross-sectional survey undertaken between November 2018 and February 2019 with leaders of CMOs (n = 76) that support people with mental health conditions in the state of New South Wales, Australia to: 1) measure the provision of preventive care (screening, support, and connections to specialist services) for five health behaviours; 2) identify the presence of key organisational features (e.g., data collection, staff training); and 3) explore if these organisational features were associated with the provision of preventive care. Preventive care provision to a majority of consumers (50% or more) was least frequently reported for tobacco smoking and most frequently reported for physical activity. Staff training and guidelines regarding the provision of preventive care were associated with the provision of such care. The results demonstrate that CMOs are already engaged in providing preventive care to some extent, with certain behaviours and preventive care elements addressed more frequently than others. Further research with additional CMO stakeholders, including staff and consumers, is needed to gain a deeper understanding of factors that may underlie CMOs capacity to routinely provide preventive care.

Background: A high proportion of vocational education students smoke tobacco, have inadequate nutrition (ie, low fruit and vegetable intake), drink alcohol at risky levels, or are physically inactive. The extent to which vocational education students will sign up for proactively offered online and telephone support services for multiple health risk behaviors is unknown. Objective: The aim of this study is to examine the uptake of proactively offered online and telephone support services for smoking, nutrition, alcohol consumption, and physical activity risk behaviors, individually and in combination, among vocational education students in the Technical and Further Education (TAFE) setting. The characteristics associated with the uptake of online or telephone services for smoking, nutrition, alcohol consumption, and physical activity risk behaviors were also examined. Methods: Vocational education students enrolled in a TAFE class in New South Wales, Australia, which ran for 6 months or more, were recruited to participate in a cluster randomized controlled trial from May 2018 to May 2019. In the intervention arm, participants who did not meet the Australian health guidelines for each of the smoking, nutrition, alcohol consumption, and physical activity risk behaviors were provided electronic feedback and proactively offered online and telephone support services. Uptake of support was measured by whether participants signed up for the online and telephone services they were offered. Results: Vocational education students (N=551; mean age 25.7 years, SD 11.1; 310/551, 56.3% male) were recruited into the intervention arm. Uptake of the proactive offer of either online or telephone services was 14.5% (59/406) for fruit and vegetables, 12.7% (29/228) for physical activity, 6.8% (13/191) for smoking, and 5.5% (18/327) for alcohol use. Uptake of any online or telephone service for at least two health behaviors was 5.8% (22/377). Participants who were employed (odds ratio [OR] 0.10, 95% CI 0.01-0.72) and reported not being anxious (OR 0.11, 95% CI 0.02-0.71) had smaller odds of signing up for online or telephone services for smoking, whereas participants who reported not being depressed had greater odds (OR 10.25, 95% CI 1.30-80.67). Participants who intended to change their physical activity in the next 30 days had greater odds (OR 4.01, 95% CI 1.33-12.07) of signing up for online or telephone services for physical activity. Employed participants had smaller odds (OR 0.18, 95% CI 0.06-0.56) of signing up for support services for at least two behaviors. Conclusions: Although the uptake of proactively offered online and telephone support services is low, these rates appear to be higher than the self-initiated use of some of these services in the general population. Scaling up the proactive offer of online and telephone services may produce beneficial health outcomes.

Issue addressed: Healthy canteen policies regulating the sales of food and beverages are available across all the states and territories in Australia. The aim of this study was to assess the compliance with a newly updated healthy school canteen policy in New South Wales (NSW) among a sample of secondary schools. Methods: A cross-sectional study of secondary school canteen menus was undertaken in selected regions across NSW (September 2017-November 2017). Government and Catholic secondary schools with a canteen menu publicly available on school websites were eligible for inclusion. Menus were classified according to the NSW Healthy School Canteen Strategy using a Quick Menu Audit tool, previously validated in primary schools. Results: Of 62 Catholic and 128 Government secondary schools located in the study region, 53 secondary schools (25 Catholic and 28 Government) were eligible to participate. The average percentage of ¿everyday¿ (healthy) items on secondary school menus was 54% (strategy criteria is >75%). Twenty-eight per cent of menus had no ¿sugary drinks¿ (should not be sold). None of the 53 menus assessed met all strategy criteria regarding the availability of foods and beverages. There was no statistically significant difference in meeting; (a) 75% minimum ¿everyday¿ items and (b) no ¿sugary drinks,¿ by socio-economic region, remoteness, school enrolments or school type. Conclusions: If public health benefits of healthy eating policies are to be realised, secondary schools need to be supported to implement such policies. So what?: Future research assessing the impact of intervention strategies to support policy implementation in secondary schools is recommended.

Background: Real-time video counselling for smoking cessation uses readily accessible software (e.g. Skype). This study aimed to assess the short-term effectiveness of real-time video counselling compared to telephone counselling or written materials (minimal intervention control) on smoking cessation and quit attempts among rural and remote residents. Methods: An interim analysis of a three-arm, parallel group randomised trial with participants (n = 655) randomly allocated to; 1) real-time video counselling; 2) telephone counselling; or 3) written materials only (minimal intervention control). Participants were daily tobacco users aged 18 years or older residing in rural or remote areas of New South Wales, Australia. Video and telephone counselling conditions offered up to six counselling sessions while those in the minimal intervention control condition were mailed written materials. The study measured seven-day point prevalence abstinence, prolonged abstinence and quit attempts at 4-months post-baseline. Results: Video counselling participants were significantly more likely than the minimal intervention control group to achieve 7-day point prevalence abstinence at 4-months (18.9% vs 8.9%, OR = 2.39 (1.34¿4.26), p = 0.003), but the video (18.9%) and telephone (12.7%) counselling conditions did not differ significantly for 7-day point prevalence abstinence. The video counselling and minimal intervention control groups or video counselling and telephone counselling groups did not differ significantly for three-month prolonged abstinence or quit attempts. Conclusion: Given video counselling may increase cessation rates at 4 months post-baseline, quitlines and other smoking cessation services may consider integrating video counselling into their routine practices as a further mode of cessation care delivery. Trial registration: www.anzctr.org.au ACTRN12617000514303.

There has been a proliferation of digital health interventions (DHIs) targeting dietary in-take. Despite their potential, the effectiveness of DHIs are thought to be dependent, in part, on user engagement. However, the relationship between engagement and the effectiveness of dietary DHIs is not well understood. The aim of this review is to describe the association between DHI engagement and dietary intake. A systematic search of four electronic databases and grey literature for records published before December 2019 was conducted. Studies were eligible if they examined a quantitative association between objective measures of engagement with a DHI (subjective experience or usage) and measures of dietary intake in adults (aged = 18 years). From 10,653 citations, seven studies were included. Five studies included usage measures of engagement and two examined subjective experiences. Narrative synthesis, using vote counting, found mixed evidence of an association with usage measures (5 of 12 associations indicated a positive relationship, 7 were in-conclusive) and no evidence regarding an association with subjective experience (both studies were inconclusive). The findings provide early evidence supporting an association between measures of usage and dietary intake; however, this was inconsistent. Further research examining the association between DHI engagement and dietary intake is warranted.

Aim: To assess the impact of a multistrategy intervention designed to improve teachers' implementation of a school physical activity (PA) policy on student PA levels. Methods: A cluster-randomized controlled trial was conducted in 12 elementary schools. Policy implementation required schools to deliver 150 minutes of organized PA for students each week via physical education, sport, or class-based activities such as energizers. Schools received implementation support designed using the theoretical domains framework to help them implement the current policy. Results: A total of 1,502 children in kindergarten to grade 6 participated. At follow-up compared with control, students attending intervention schools had, measured via accelerometer, significantly greater increases in school day counts per minute (97.5; 95% confidence interval [CI], 64.5 to 130.4; P <.001) and moderate to vigorous physical activity (MVPA) (3.0; 95% CI, 2.2-3.8, P <.001) and a greater decrease in sedentary time (-2.1; 95% CI, -3.9 to -0.4, P =.02) per school day. Teachers in intervention schools delivered significantly more minutes (36.6 min) of PA to their students at follow-up (95% CI, 2.7-70.5, P =.04). Conclusions: Supporting teachers to implement a PA policy improves student PA. Additional strategies may be needed to support teachers to implement activities that result in larger gains in student MVPA.

Introduction and Aims: People who use substances have a high prevalence of modifiable chronic disease health risk behaviours. Preventive care to address such risks has not traditionally been provided during substance use treatment. This study aimed to assess clinicians' attitudes towards preventive care and their association with care provision. Design and Methods: A cross-sectional study utilising computer-assisted telephone interviews was undertaken with clinicians (n = 54) of community-based substance use treatment services in one health district, Australia. Clinicians indicated their agreement with 10 attitudinal statements regarding their perceived role and self-efficacy in providing preventive care and perceptions of client interest in modifying behaviours. Logistic regression analyses examined the association between clinician attitudinal items and self-reported care provision. Results: Fifty-four clinicians (74%) agreed to participate. The most positive attitudes were preventive care being part of their role (100%), and they have the knowledge and skills to provide preventive care (100%). The least favourable attitude was clients were interested in changing their health risk behaviours (60%). Clinicians who reported that preventive care left little time to undertake acute care were more likely to assess for smoking (OR 8.06 [95% CI 1.31, 49.46]) and less likely to provide brief advice for all risks combined (OR 0.11 [95% CI 0.02, 0.63]). Discussion and Conclusions: Overall, clinicians reported positive attitudes regarding the preventive care provision for modifiable health risk behaviours in substance use treatment settings. Further research is required to investigate why, despite such positive attitudes, clinicians in substance use treatment settings do not routinely provide preventive care.

Issue addressed: Supporting centre-based childcare services to create physical activity (PA) environments is a recommended strategy to improve child PA. This study aimed to describe the implementation of PA policies and practices by these services, and to examine the associations with service characteristics. Methods: Nominated supervisors of childcare services (n¿=¿309) in the Hunter New England region, New South Wales, Australia, completed a telephone interview. Using previously validated measures, the interview assessed the implementation of evidence-based practices shown to be associated with child PA. This includes: (a) provision of active play opportunities, (b) portable play equipment availability, (c) delivery of daily fundamental movement skills, (d) having at least 50% of staff trained in promoting child PA the past 5¿years and (e) having written PA and small screen recreation policies. Results: Although 98% (95% CI 96, 99) of childcare services provided active play opportunities for at least 25% of their daily opening hours, only 8% (95% CI 5, 11) of services fully implemented all policies and practices; with no service characteristic associated with full implementation. Long day care service had twice the odds of having a written PA policy (OR 2.0, 95% CI 0.7, 5.8), compared to preschools (adjusted for service size, socio-economic disadvantage and geographical location). Conclusions: Improvements could be made to childcare services¿ operations to support the promotion of child PA. So what?: To ensure the benefits to child health, childcare services require support to implement a number of PA promoting policies and practices that are known to improve child PA.

Issue addressed: The aim of this study was to assess potential barriers to the implementation of clinical guideline recommendations regarding maternal alcohol consumption by antenatal clinicians and managers. Methods: Cross-sectional surveys of antenatal clinicians and managers employed in a New South Wales Local Health District were undertaken. Survey items were developed based on 11 domains of the Theoretical Domains Framework. Consistent with previous studies, a cut point of less than 4 was applied to mean values of survey items (range: 1-5) to identify domains representing barriers to the implementation. Results: Thirty-three antenatal clinicians and eight managers completed the surveys. For clinicians, the domains with the lowest mean values included ¿environmental context and resources¿ (ie, complexity of appointments and availability of supporting systems) (mean: 3.13, SD: 0.93); ¿social influences¿ (ie, expectations of others that alcohol will be addressed) (mean: 3.33, SD: 0.68); ¿beliefs about capabilities¿ (ie, confidence in providing guideline recommendations) (mean: 3.51, SD: 0.67); and ¿behavioural regulation¿ (ie, planning and responding to feedback) (mean: 3.53, SD: 0.64). For managers, ¿emotion regulation¿ (ie, stress in managing change) (mean: 2.13, SD: 0.64) and ¿environmental context and resources¿ (ie, complexities of managing change) (mean: 3.13, SD: 0.83) were the lowest scoring domains. Conclusions: The antenatal service environment and availability of resources appear to be primary barriers to both clinicians and managers implementing guidelines for maternal alcohol consumption. So what?: In the development of interventions to support the delivery of clinical guideline recommendations addressing alcohol consumption during pregnancy, a broad range of potential barriers at both the clinician and manager levels need to be considered and targeted by effective implementation strategies.

Little is known about the long-term impact of telephone-based interventions to improve child diet. This trial aimed to assess the long-term effectiveness (after 5 years) of a telephone-based parent intervention in increasing children¿s fruit and vegetable consumption. Parents of 3¿5 year olds were recruited from 30 Australian preschools to participate in a cluster randomised controlled trial. Intervention parents received four, weekly, 30-min support calls aimed at modifying the home food environment. Control parents received printed materials. Consumption was assessed using the Fruit and Vegetable subscale of the Children¿s Dietary Questionnaire (F&V-CDQ) (children) and daily servings of fruit and vegetables (children and parents) via parent telephone interview. Of the 394 parents who completed baseline, 57% (99 intervention, 127 control) completed follow-up. After 5-years, higher intervention F&V-CDQ scores, bordering on significance, were found in complete-case (+1.1, p = 0.06) and sensitivity analyses (+1.1, p = 0.06). There was no difference in parent or child consumption of daily fruit servings. Complete-case analysis indicated significantly higher consumption of child vegetable servings (+0.5 servings; p = 0.02), which was not significant in sensitivity analysis (+0.5 servings; p = 0.10). This telephone-based parent intervention targeting the family food environment may yield promising improvements in child fruit and vegetable consumption over a 5-year period.

Although it is recommended that childcare centers provide foods consistent with dietary guidelines, the impact of implementing sector-specific guidelines on child outcomes is largely unknown. Objectives: This study aims to examine the impact of a web-based program and support to implement dietary guidelines in childcare centers on children's 1) diet; 2) BMI z scores; and 3) child health-related quality of life (HRQoL). Methods: This study was a cluster-randomized controlled trial utilizing a Type-3 Hybrid implementation-effectiveness design conducted between October 2016 and March 2018. This study reports on child outcomes. Fifty-four childcare centers in New South Wales, Australia were randomly assigned to the intervention (a web-based menu-planning tool and support) or control group (usual care). The intervention was designed to address barriers and enablers to dietary guideline implementation according to the Theoretical Domains Framework. A quota of 35 consenting childcare centers undertook child-level evaluation of dietary intake where 522 parents consented to completing =1 component of data collection for their child. Child consumption of core and discretionary (unhealthy) foods while in care was assessed via dietary observations by blinded research assistants, childcare diet quality was assessed via educator-completed questionnaires, BMI z scores were assessed via measured weight and height, and child HRQoL was assessed via parent report at baseline and 12-mo follow-up. Results: There was a significant increase in mean child consumption of fruit (0.39 servings; 95% CI: 0.12, 0.65 servings) and dairy foods (0.38 servings; 95% CI: 0.19, 0.57 servings) and a significant reduction in consumption of discretionary foods (-0.40 servings; 95% CI: -0.64, -0.16 servings) in care in the intervention group, relative to control at 12-mo follow-up. No significant differences were observed in diet quality, BMI z scores, or HRQoL. Conclusions: A web-based intervention to support planning of childcare menus consistent with dietary guidelines can improve child consumption of healthier foods in daycare. This trial was registered at www.anzctr.org.au as ACTRN12616000974404.

Objective: To assess the effectiveness of weight-loss interventions on pain and disability in people with knee and hip osteoarthritis (OA) and spinal pain. Design: Intervention systematic review. Literature Search: Twelve online databases and clinical trial registries. Study Selection Criteria: Randomized controlled trials of any weight-loss intervention (eg, diet, physical activity, surgical, pharmaceutical) that reported pain or disability outcomes in people with knee or hip OA or spinal pain. Data Synthesis: We calculated mean differences or standardized mean differences (SMDs) and 95% confidence intervals (CIs). We used the Cochrane risk of bias tool to assess risk of bias and the Grading of Recommendations Assessment, Development, and Evaluation tool to judge credibility of evidence. Results: Twenty-two trials with 3602 participants were included. There was very low- to very low-credibility evidence for a moderate effect of weight-loss interventions on pain intensity (10 trials, n = 1806; SMD, -0.54; 95% CI: -0.86, -0.22; I2 = 87%, P<.001) and a small effect on disability (11 trials, n = 1821; SMD, -0.32; 95% CI: -0.49, -0.14; I2 = 58%, P <.001) compared to minimal care for people with OA. For knee OA, there was low- to moderate-credibility evidence that weight-loss interventions were not more effective than exercise only for pain intensity and disability, respectively (4 trials, n = 673; SMD, -0.13; 95% CI: -0.40, 0.14; I2 = 55%; 5 trials, n = 737; SMD, -0.20; 95% CI: -0.41, 0.00; I2 = 32%). Conclusion: Weight-loss interventions may provide small to moderate improvements in pain and disability for OA compared to minimal care. There was limited and inconclusive evidence for weight-loss interventions targeting spinal pain.

Objective: To examine: alcohol and fast food sponsorship of junior community sporting clubs; the association between sponsorship and club characteristics; and parent and club representative attitudes toward sponsorship. Methods: A cross-sectional telephone survey of representatives from junior community football clubs across New South Wales and Victoria, Australia, and parents/carers of junior club members. Participants were from junior teams with Level 3 accreditation in the ¿Good Sports¿ program. Results: A total of 79 club representatives and 297 parents completed the survey. Half of participating clubs (49%) were sponsored by the alcohol industry and one-quarter (27%) were sponsored by the fast food industry. In multivariate analyses, the odds of alcohol sponsorship among rugby league clubs was 7.4 (95%CI: 1.8¿31.0, p=<0.006) that of AFL clubs, and clubs located in regional areas were more likely than those in major cities to receive fast food industry sponsorship (OR= 9.1; 95%CI: 1.0¿84.0, p=0.05). The majority (78¿81%) of club representatives and parents were supportive of restrictions to prohibit certain alcohol sponsorship practices, but a minority (42%) were supportive of restrictions to prohibit certain fast food sponsorship practices. Conclusions: Large proportions of community sports clubs with junior members are sponsored by the alcohol industry and the fast food industry. There is greater acceptability for prohibiting sponsorship from the alcohol industry than the fast food industry. Implications for public health: Health promotion efforts should focus on reducing alcohol industry and fast food industry sponsorship of junior sports clubs.

The study aimed to compare the effectiveness of a suite of implementation strategies of varying intensities on centre-based childcare service implementation of nutrition guideline recommendations at 12-month follow-up. A six-month three-arm parallel group randomised controlled trial was undertaken with 69 services, randomised to one of three arms: high-intensity strategies (executive support; group face-to-face training; provision of resources; multiple rounds of audit and feedback; ongoing face-to-face and phone support); low-intensity strategies (group face-to-face training; provision of resources; single round of audit and feedback); or usual care control. Across all study arms, only three high-intensity services were compliant with overall nutrition guidelines. A significant group interaction was found between the three arms for compliance with individual food groups. Relative to control, a significantly greater proportion of low-intensity services were compliant with dairy, and a significantly greater proportion of high-intensity services were compliant with fruit, vegetables, dairy, breads and cereals, and discretionary foods. No significant differences between the high-and low-intensity for individual food group compliance were found. High-intensity implementation strategies may be effective in supporting childcare service implementation of individual food group recommendations. Further research is warranted to identify strategies effective in increasing overall nutrition compliance.

Objectives: Implementation interventions applied in public health are about using proven strategies to influence the uptake of evidence-based prevention and health promotion initiatives. The decision to invest in implementation has an opportunity cost, which can be overlooked. The purpose of this study was to assess the extent to which economic evaluations have been applied to implementation interventions in public health. Study design: We conducted a systematic review of empirical studies examining the costs and consequences, cost-effectiveness or cost-benefit of strategies directed towards enhancing the implementation of public health interventions and policies in developed countries. Methods: The following databases were searched for English language publications reporting both effect measures and costs, from 1990 to current: MEDLINE, Embase, PsycINFO, CINAHL, EconLit, EPPI-Centre database of health promotion research, Cost-Effectiveness Analysis Registry, NHS Economic Evaluation Database, Informit and Scopus. Results: The search strategy returned 3229 records after duplicate removal, from which we included 14 economic evaluations. All the included evaluations were conducted and published after 2000. Twelve of the 14 evaluations were based on controlled trials and two reported hypothetical modelled scenarios. The methodologic rigour and compliance with reporting guidelines for economic evaluations was highly varied and not related to the publication date. Conclusions: Our findings offer the first insight into the application and methodologic rigour of economic evaluations of implementation strategies supporting public health policies and interventions. To usefully inform public health policy and investment decisions, there needs to be greater application of economic evaluation to understand the cost-effectiveness of alternative implementation efforts. This review highlights the great paucity and mixed quality of the evidence on this topic and offers guidance by way of a checklist to improve the quality and reporting of future evaluations.

Background: Economic evaluations which estimate cost-effectiveness of potential treatments can guide decisions about real-world healthcare services. We performed an economic evaluation of a healthy lifestyle intervention targeting weight loss, physical activity and diet for patients with chronic low back pain, who are overweight or obese. Methods: Eligible patients with chronic low back pain (n¿=¿160) were randomized to an intervention or usual care control group. The intervention included brief advice, a clinical consultation and referral to a 6-month telephone-based healthy lifestyle coaching service. The primary outcome was quality-adjusted life years (QALYs). Secondary outcomes were pain intensity, disability, weight and body mass index. Costs included intervention costs, healthcare utilization costs and work absenteeism costs. An economic analysis was performed from the societal perspective. Results: Mean total costs were lower in the intervention group than the control group (-$614; 95%CI: -3133 to 255). The intervention group had significantly lower healthcare costs (-$292; 95%CI: -872 to -33), medication costs (-$30; 95%CI: -65 to -4) and absenteeism costs (-$1,000; 95%CI: -3573 to -210). For all outcomes, the intervention was on average less expensive and more effective than usual care, and the probability of the intervention being cost-effective compared to usual care was relatively high (i.e., 0.81) at a willingness-to-pay of $0/unit of effect. However, the probability of cost-effectiveness was not as favourable among sensitivity analyses. Conclusions: The healthy lifestyle intervention seems to be cost-effective from the societal perspective. However, variability in the sensitivity analyses indicates caution is needed when interpreting these findings. Significance: This is an economic evaluation of a randomized controlled trial of a healthy lifestyle intervention for chronic low back pain. The findings suggest that a healthy lifestyle intervention may be cost-effective relative to usual care.

Objective: To assess the nutritional quality of student canteen purchases at recess and lunch, including: (i) the mean energy (kilojoules), saturated fat (grams), total sugar (grams) and Na (milligrams) and percentage of energy from saturated fat and total sugar; and (ii) the proportion and types of foods purchased that are healthier (green) and less healthy (amber/red) according to a state school canteen policy.Design: A cross-sectional study of student canteen food and beverage recess and lunch purchases.Setting: Twenty-six randomly selected government primary schools that were non-compliant with a state school canteen policy from a region of New South Wales, Australia, were approached to participate.Participants: Students (aged 5-12 years) of participating schools.Results: Eighteen schools (69 %) consented to participate. On average students' recess purchases contained 571·2 kJ energy, 1·6 g saturated fat, 11·6 g total sugar and 132·4 mg Na with 10·0 % of energy from saturated fat and 37·8 % of energy from total sugar. Students' lunch purchases contained 685·4 kJ energy, 1·8 g saturated fat, 12·7 g total sugar and 151·4 mg Na with 9·5 % of energy from saturated fat and 31·8 % of energy from total sugar. Less healthy items represented 72 and 76 % of all items purchased at recess and lunch, respectively, with 'savoury snacks' and 'sugar-sweetened ice blocks and slushies' being the most common recess and lunch purchases, respectively.Conclusions: There is considerable scope to improve the nutritional quality of student purchases from primary-school canteens, with a high percentage of energy from total sugar. Future research is required to identify effective strategies to enhance compliance with canteen policies and support the purchase of healthier foods from school canteens.

Purpose: To assess the causal mechanisms of a healthy lifestyle intervention for patients with chronic low back pain and knee osteoarthritis, who are overweight or obese. Methods: We conducted causal mediation analyses of aggregated data from two randomized controlled trials (RCTs); which included 160 patients with chronic low back pain, and 120 patients with knee osteoarthritis. The intervention consisted of brief advice and referral to a six-month telephone-based healthy lifestyle coaching service. We used causal mediation to estimate the indirect, direct and path-specific effects of hypothesized mediators including: self-reported weight, diet, physical activity, and pain beliefs. Outcomes were pain intensity, disability, and quality of life (QoL). Results: The intervention did not reduce weight, improve diet or physical activity or change pain beliefs, and these mediators were not associated with the outcomes. Sensitivity analyses showed that our estimates were robust to the possible effects of unknown and unmeasured confounding. Conclusions: Our findings show that the intervention did not cause a meaningful change in the hypothesized mediators, and these mediators were not associated with patient-reported outcomes.

Issue addressed: Improving implementation of school healthy canteen policies requires a comprehensive understanding of implementation barriers. Therefore, the aim of this study was to assess a range of barriers, as reported by canteen managers, using a quantitative survey instrument developed based on a theoretical framework. Methods: A cross sectional survey of primary school canteen managers from the Hunter New England region of New South Wales was conducted of eligible schools in the study region identified as having an operational canteen. Survey items assessed canteen manager employment status, canteen characteristics and potential barriers to healthy canteen policy implementation, aligned to the 14 domains of the theoretical domains framework via a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The mean domain scores of canteen managers were calculated, less than four indicating the canteen manager considered the domain was a barrier. Canteen managers were also asked to provide the current canteen menu for audit by a dietitian. Results: Of the 184 participants, 20% (n¿=¿36) were assessed as having menus compliant with the state policy. The five most common domains identified as potential barriers to policy implementation were behavioural regulation (n¿=¿117, 65%), skills (n¿=¿105, 57%), beliefs about capabilities (n¿=¿100, 55%), reinforcement (n¿=¿95, 52%) and goals (n¿=¿95, 52%). Canteen managers who reported optimism as a barrier had significantly lower odds of having a menu compliant with the state policy (OR¿=¿0.39; 95% CI 0.16-0.95, P¿=¿0.038). Conclusions: This study provides further evidence of perceived and actual barriers that canteen managers face when attempting to implement a healthy canteen policy, and highlights the need to address differences in canteen characteristics when planning implementation support. So what?: For public health benefits of nutrition policies within schools to be realised, the barriers to implementation need to be identified and used to help guide implementation support strategies.

Issues addressed: To: (i) describe the prevalence of policies and practices promoting healthy eating implemented by sports clubs with junior teams; (ii) examine differences in such practices across geographic and operational characteristics of clubs; and (iii) describe the attitudes of club representatives and parents regarding the acceptability of sports clubs implementing policies and practices to promote healthy eating. Methods: Cross-sectional telephone surveys of junior community football club management representatives and parents/carers of junior players were conducted in the states of New South Wales and Victoria, Australia in 2016. Results: Seventy-nine of the 89 club representatives approached to participate completed the telephone survey. All clubs (100%; 95% CI 96.2-100.0) reported recommending fruit or water be provided to players after games or at half-time, 24% (95% CI 14.4-33.7) reported promoting healthy food options through prominent positioning at point of sale and only 8% (95% CI 1.6-13.6) of clubs had a written healthy eating policy. There were no significant differences between the mean number of healthy eating policies and practices implemented by club socio-economic or geographic characteristics. Club representatives and parents/carers were supportive of clubs promoting healthy eating for junior players. Conclusions: While there is strong support within sporting clubs with junior teams for policies and practices to promote healthy eating, their implementation is highly variable. So what?: A considerable opportunity remains for health promotion policy and practice improvement in clubs with junior teams, particularly regarding policies related to nutrition.

The persistent prevalence of childhood overweight and obesity raises significant concerns about the impact on health, society and the economy. Responding to a target announced in September 2015 by the New South Wales (Australia) Premier to reduce childhood overweight and obesity by five percentage points by 2025, a system dynamics model was developed to support Government and stakeholders responsible for meeting the target. A participatory model building process, drawing cross-sectorial expertise, was undertaken to estimate the individual and combined impact of interventions on meeting the target. The model demonstrated that it is theoretically possible to meet the target by implementing a comprehensive combination of policies and programmes. When limited to existing and enhanced population health interventions, the modelled result did not reach the target. The project provides an example of how participatory simulation modelling can combine a broad range of interventions together into likely scenarios and usefully inform government decision-making. © 2018 The authors. Systems Research and Behavioral Science published by International Federation for Systems Research and John Wiley & Sons Ltd.

Issue addressed: School-based nutrition policies can have a positive effect on the school food environment. The primary aim of this study was to assess the primary school adherence to a mandatory state-wide healthy canteen policy 12¿months after an effective multi-strategic implementation intervention concluded. Methods: Primary schools were randomised to (a) a 12-14¿months multi-strategic intervention or (b) no-intervention (control). The intervention aimed to improve implementation of a state-wide canteen policy by encouraging schools to remove unhealthy food and beverages (classified as ¿¿red¿¿ or ¿¿banned¿¿) from canteen menus and replace with healthy items (classified as ¿¿green¿¿). No implementation support was provided to either group by the research team between the 12 and 24¿months data collection period. Results: Seventy schools participated, of which 56 schools were assessed at 24-month follow-up. Intervention schools were less likely to have a menu which contained ¿¿red/banned¿¿ items at 24-month follow-up (RR¿=¿2.28; 95% CI: 1.18-4.40; P¿=¿0.01). Intervention schools, however, were not more likely than controls to have a menu which contained >50% ¿¿green¿¿ items at 24-month follow-up (RR¿=¿1.29; 95% CI: 0.98-1.70; P¿=¿0.10). Intervention schools were more likely to adhere to both policy components (no red/banned items and >50% green items on the menu) than control schools (RR¿=¿2.61; 95% CI: 1.29-5.29; P¿=¿0.006). Among intervention schools that were fully adherent to the policy following implementation support (12-month post baseline), all were also adherent at the 24-month follow-up. Conclusion: The intervention was effective in achieving long-term school adherence to a state-wide canteen policy at 24-month follow-up. So what?: The findings suggest that sustained improvements in implementation of school nutrition policies is possible following a period (12¿months) of comprehensive implementation support.

The primary aim of this study was to assess the efficacy of a childcare-based intervention in increasing child physical activity by allowing children unrestricted access to outdoor areas for free-play when structured activity is not taking place. A randomized controlled trial was conducted in six childcare services. Intervention services provided children unrestricted access outdoors for active free-play, while control services provided their usual scheduled periods of outdoor play. Consent was obtained from 231 children. Child moderate to vigorous activity (MVPA), the primary trial outcome, was assessed via accelerometer at baseline and 3 months post baseline. Intervention effects were examined using Generalised Linear Mixed Models. Controlling for child age, gender and baseline outcome measure, at follow-up there were no significant differences between groups in minutes of MVPA in-care (mean difference: 4.85; 95% CI: -3.96, 13.66; P = 0.28), proportion of wear time in-care spent in MVPA (mean difference: 1.52%; 95% CI: -0.50, 3.53; P = 0.14) or total physical activity in-care (mean difference in counts per minute: 23.18; 95% CI: -4.26, 50.61; P = 0.10), nor on measures of child cognition (P = 0.45-0.91). It was concluded that interventions addressing multiple aspects of the childcare and home environment might provide the greatest potential to improve child physical activity.

Aims and objectives: To explore the quantitative and qualitative literature on the impact of nurse-led postdischarge telephone follow-up (TFU) call interventions on patient outcomes. Background: Adverse patient outcomes such as postdischarge problems, premature contact with health systems, inability to self-manage conditions and hospital readmissions all have¿an impact on the health and well-being, and satisfaction of patients as well as a financial impact on healthcare systems. Design: A mixed-study systematic review. Review methods: A systematic search of CINAHL, Ebsco, PubMed, Quest and Cinch-Health databases was undertaken using the key terms ¿nurs*,¿ ¿nurse-led,¿ ¿nurse initiated,¿ ¿discharge,¿ ¿hospital,¿ ¿telephone,¿ ¿follow-up¿ and ¿telephone follow-up¿ to identify relevant original peer-reviewed studies published between 2010¿2016. Ten articles were selected for inclusion. The selected papers were critically appraised. A sequential explanatory approach with a convergent synthesis was used to report findings following PRISMA guidelines. Results: The findings demonstrate that nurse-led TFU interventions have the potential to improve patient outcomes. The studies suggest patient satisfaction with TFU is one of the strongest positive outcomes from the interventions. However, the results do not support improvement in patient readmission or mortality. Conclusions: Of the 10 studies reviewed, only two were methodologically strong limiting the conclusions that can be drawn from the current research on this topic. Telephone follow-up interventions improve patient satisfaction and have the potential to meet patient information and communication needs, improve self-management and follow-up appointment attendance and reduce postdischarge problems. Further research is required to explore patients¿ perceptions of the most useful content of TFU calls, the efficacy of TFU calls and nurses¿ perceptions and experiences of conducting TFU interventions. Relevance to clinical practice: When conducted by a nurse, these interventions have the potential to enhance postdischarge care to patients and meet care needs. Patients perceive TFU as acceptable and are satisfied with this form of postdischarge care.

Purpose: To assess the efficacy of a food service implementation intervention designed to increase provision of foods consistent with nutrition guidelines on child consumption of fruit, vegetables, breads/cereals, meat/alternatives, dairy, and diet quality in care. Design: Exploratory cluster randomized controlled trial. Setting: Twenty-five childcare centers in New South Wales, Australia. Sample: Three hundred ninety-five children aged 2 to 5 years. Intervention: Centers were randomized to the intervention or control group. Intervention development was guided by the Theoretical Domains Framework and included securing executive support, provision of group training, resources, audit and feedback, and one-on-one support. The intervention was delivered across six months and the study was conducted between March and December 2016. Measures: Child diet was assessed by educators using a validated questionnaire modified for completion in childcare center. Analysis: Data were analyzed in SAS using generalized linear mixed models adjusted for clustering. Results: Children in the intervention group consumed significantly higher number of serves of vegetables (0.4 serves; P <.001), wholegrain cereals (0.7 serves; P =.02), and meat/alternatives (0.5 serves; P <.001), and had higher diet quality scores (10.3; P <.001). Conclusions: A food service intervention targeting the provision of food significantly improved child dietary intake in care. Such findings are relevant to health promotion practitioners responsible for supporting improvements in child diet.

Implementation of interventions in community organisations such as schools, childcare centres, and sporting clubs are recommended to target a range of modifiable risks of non-communicable diseases. Poor implementation, however, is common and has contributed to the failure of non-communicable disease interventions globally. This study aimed to characterise experimental research regarding strategies to improve implementation of chronic disease prevention programs in community settings. The review used data collected in three comprehensive systematic reviews undertaken between August 2015 and July 2017. Randomised controlled trials, including cluster design, and non-randomised trials with a parallel control group were included. The data were extracted to describe trial characteristics, implementation strategies employed, implementation outcomes and study quality. Of the 40 implementation trials included in the study, unhealthy diet was the most common risk factor targeted (n = 20). The most commonly reported implementation strategies were educational meetings (n = 38, 95%), educational materials (n = 36, 90%) and educational outreach visits (n = 29, 73%). Few trials were conducted ¿at-scale¿ (n = 8, 20%) or reported adverse effects (n = 5, 13%). The reporting of implementation related outcomes; intervention adoption (n = 13, 33%); appropriateness (n = 11, 28%); acceptability (n = 8, 20%); feasibility (n = 8, 20%); cost (n = 3, 8%); and sustainability (n = 2, 5%); was limited. For the majority of trials, risk of bias was high for blinding of study personnel/participants and outcome assessors. Testing of strategies to improve implementation of non-communicable disease prevention strategies in community settings, delivered ¿at-scale¿, utilising implementation frameworks, including a comprehensive range of implementation outcomes should be priority areas for future research in implementation science.

Objective: Sports clubs have been identified as settings where high levels of risky alcohol consumption occurs. Settings characterised by such behaviour are likely to negatively impact on levels of safety, participation and amenity. Design: The study was part of a randomised control trial, designed to help community sports clubs responsibly manage the sale and consumption of alcohol; the primary outcome was reduction in alcohol consumption. This study examined the secondary effects of safety and participation. Methods: A multilevel analysis examining the pathways between the alcohol intervention, risky alcohol consumption, and safety and participation was undertaken. Results: It was identified that average overall risky consumption at the club level mediated the association between the intervention and increased participation; the intervention reduced overall hazardous consumption, which in turn increased participation at the club. Conclusion: Interventions that target responsible alcohol management can also increase club participation. Implications for public health: Given the number of individuals involved with sports clubs, responsibly managing alcohol will also ensure that sports clubs are health promoting settings that promote community participation and engagement.

BACKGROUND: During adolescence, prevalence of pain and health risk factors such as smoking, alcohol use and poor mental health all rise sharply. The aim of this study was to describe the relationship between back pain and health risk factors in adolescents. METHODS: Cross-sectional data from the Healthy Schools Healthy Futures study, and the Australian Child Wellbeing Project was used, mean age: 14-15 years. Children were stratified according to back pain frequency. Within each strata, the proportion of children that reported drinking alcohol or smoking or that experienced feelings of anxiety or depression was reported. Test-for-trend analyses assessed whether increasing frequency of pain was associated with health risk factors. RESULTS: Data was collected from ~2500 and 3900 children. Larger proportions of children smoked or drank alcohol within each strata of increasing pain frequency. The trend with anxiety and depression was less clear, although there was a marked difference between the children that reported no pain, and pain more frequently. CONCLUSION: Two large, independent samples show adolescents that experience back pain more frequently are also more likely to smoke, drink alcohol and report feelings of anxiety and depression. Pain appears to be part of the picture of general health risk in adolescents.

Background: Socio-ecological models indicate that family, school, and¿community environment explains children¿s physical activity and body weight. This study investigated whether parental perceptions of school/community-based physical activity (PA) promotion programs as well as parental and child perceptions of parental instrumental support for child PA (transportation provision) would predict child body weight. Child moderate-to-vigorous physical activity (MVPA) was hypothesized to mediate these associations. Method: Data of 879 parent-child dyads were collected at two measurement points: the baseline (T1) and the 7¿8-month follow-up (T2). Parents were 23¿68¿years old (83.3% women), while children were 5¿11¿years old (52.4% girls). Parents and children reported their perceptions of environment, support (T1), and MVPA (T1, T2). Parental and child body weight and height were measured objectively (T1, T2). Results: Path analyses indicated indirect effects of parental perceptions of school/community-based PA policies (T1) and parental perceptions of transportation provision (T1) on child body weight (T2), with child MVPA (T2) operating as the mediator. There were no direct or indirect effects of child perceptions of parental transportation provision (T1) on child MVPA or body weight (T2). Similar patterns of associations were found for the total sample and the subsample of children with overweight/obesity. Conclusion: Parental perceptions of school/community-based PA policies and transportation provision may explain changes in child MVPA and body weight. Interventions aimed at prevention of child overweight/obesity may benefit from a focus on parental transportation provision to PA facilities and parental awareness of PA promotion at local environment.

Introduction and Aims: Those involved in organised sport have a high risk of excessive alcohol consumption and alcohol-related harm, the implementation of alcohol management practices have been proven to reduce these risks. Measuring alcohol management practice implementation by sporting clubs is impeded by a lack of valid tools. The aim of this study was to determine the validity of online self-report of alcohol-management practices by community football clubs via comparison with observational methods. Design and Methods: A cross-sectional study was undertaken with a sample of community football clubs within Australia. The implementation of 12 alcohol management practices was collected via: (i) an online survey; and (ii) observational audit at a clubs home ground. The prevalence of implementation of alcohol management practices for both data collection methods was calculated as was percent agreement and Kappa/Prevalence Adjusted and Bias Adjusted Kappa (PABAK) statistics. Results: Data were collected from 58 football clubs. For both assessment methods, implementation prevalence was greater than 80% for 6 of the 12 alcohol management practices. A total of 75% (n = 9) of practices had at least 70% agreement between the online and observation methods of assessment. Kappa/PABAK scores ranged from -0.08 (poor agreement) to 0.97 (almost perfect agreement). Discussion and Conclusion: The online survey provided valid measure of assessing some but not all alcohol management practices in community sporting clubs. The validity of the measure may be improved by enhancements to the manner in which the self-report data are collected.

Objective: To describe the prevalence and change in prevalence of electronic nicotine delivery systems (ENDS) use in youth by country and combustible smoking status. Methods: Databases and the grey literature were systematically searched to December 2015. Studies describing the prevalence of ENDS use in the general population aged =20 years in a defined geographical region were included. Where multiple estimates were available within countries, prevalence estimates of ENDS use were pooled for each country separately. Results: Data from 27 publications (36 surveys) from 13 countries were included. The prevalence of ENDS ever use in 2013¿2015 among youth were highest in Poland (62.1%; 95%CI: 59.9-64.2%), and lowest in Italy (5.9%; 95%CI: 3.3-9.2%). Among non-smoking youth, the prevalence of ENDS ever use in 2013¿2015 varied, ranging from 4.2% (95%CI: 3.8-4.6%) in the US to 14.0% in New Zealand (95%CI: 12.7-15.4%). The prevalence of ENDS ever use among current tobacco smoking youth was the highest in Canada (71.9%, 95%CI: 70.9-72.8%) and lowest in Italy (29.9%, 95%CI: 18.5-42.5%). Between 2008 and 2015, ENDS ever use among youth increased in Poland, Korea, New Zealand and the US; decreased in Italy and Canada; and remained stable in the UK. Conclusions: There is considerable heterogeneity in ENDS use among youth globally across countries and also between current smokers and non-smokers. Implications for public health: Population-level survey data on ENDS use is needed to inform public health policy and messaging globally.

Objective: Individual and environmental resilience protective factors are suggested to be associated with adolescent condom use; however, previous studies have not comprehensively examined such associations. This study aimed to determine the associations between condom use, and numerous individual and environmental resilience protective factors in sexually active Australian adolescents. Methods: Participants were Grade 10 students attending 28 Australian government high schools (n=1,688). An online survey (2011) collected data regarding: sexual intercourse (past year), condom use and 14 individual and environmental resilience protective factors. Multivariable backward stepwise logistic regression models examined associations between student condom use and protective factors (total, subscale). Results: Only total environmental protective factors remained in the final total score model; students with higher total environmental protective factors scores were 2.59 times more likely to always use a condom(95%CI:1.80-3.74). Only three of 14 protective factor subscales were associated with a higher likelihood of always using a condom in the final subscale model (individual: goals/aspirations; environmental: community participation, pro-social peers). Conclusions: Total environmental and three protective factor subscales demonstrated prominent associations with consistent use of condoms in sexually active adolescents. Implications for public health: Consideration of particular resilience protective factors in adolescent sexual risk behaviour prevention, such as condom use, is warranted.

Objective: To determine the effectiveness of telephone-based weight loss support in reducing the intensity of knee pain in patients with knee osteoarthritis, who are overweight or obese, compared to usual care. Design: We conducted a parallel randomised controlled trial (RCT), embedded within a cohort multiple RCT of patients on a waiting list for outpatient orthopaedic consultation at a tertiary referral hospital in NSW, Australia. Patients with knee osteoarthritis, classified as overweight or obese [body mass index (BMI) between =27 kg/m2 and <40 kg/m2] were randomly allocated to receive referral to an existing non-disease specific government funded 6-month telephone-based weight management and healthy lifestyle service or usual care. The primary outcome was knee pain intensity measured using an 11-point numerical rating scale (NRS) over 6-month follow-up. A number of secondary outcomes, including self-reported weight were measured. Data analysis was by intention-to-treat according to a pre-published analysis plan. Results: Between May 19 and June 30 2015, 120 patients were randomly assigned to the intervention (59 analysed, one post-randomisation exclusion) or usual care (60 analysed). We found no statistically significant between group differences in pain intensity [area under the curve (AUC), mean difference 5.4, 95%CI: -13.7 to 24.5, P = 0.58] or weight change at 6 months (self-reported; mean difference -0.4, 95%CI: -2.6 to 1.8, P = 0.74). Conclusions: Among patients with knee osteoarthritis who are overweight, telephone-based weight loss support, provided using an existing 6-month weight management and healthy lifestyle service did not reduce knee pain intensity or weight, compared with usual care. Trial registration number: ACTRN12615000490572

Objective This paper describes the 4-year journey of Hunter and New England HealthPathways - a password-protected web-based portal designed to provide localised evidence-informed clinical and referral information to support general practice at the point of care. Methods A process evaluation was conducted in 2013, with a case study comparison performed in 2014 to assess impact of HealthPathways on patient referral and access to specialist care, followed by a review in 2016 of utilisation of the online portal to assess whether healthcare providers continued to access HealthPathways. Results Increased utilisation was correlated with an increase in the number of pathways published online. Clinical leadership and the process of developing pathways built relationships between primary care and specialist teams. Case studies indicated that a comprehensive approach to pathway implementation accompanied by service redesign resulted in higher pathway use and improved access to specialist care. Senior management support and a formal partnership between major health care providers led to strong governance of HealthPathways and the delivery of other integrated care initiatives. There was significant growth in utilisation over the 4 years, increasing to an average of 6679 sessions per month in 2016 and more general practices reported use of HealthPathways. Conclusions HealthPathways is a vehicle for building strong foundations to support system change and integrated care. The critical elements for acceptability, growth and sustainability are the strong relationships between primary care and specialist clinicians, as well as formal partnerships that are built from the processes used to develop HealthPathways. What is known about the topic? HealthPathways and similar web-based evidence-informed guidelines aimed at improving system integration are increasing in Australia. There are few published papers that describe approaches to inform the ongoing implementation of such programs. What does this paper add? This paper describes iterative methodology for evaluating complex programs, such as HealthPathways, that identifies the critical factors required to build sustainable models of integrated care. What are the implications for practitioners? The 4-year experience of Hunter and New England HealthPathways provides an approach to improve the implementation, sustainability and spread of similar programs and associated integrated care initiatives.

Introduction: Childhood obesity prevalence is an issue of international public health concern and governments have a significant role to play in its reduction. The Healthy Children Initiative (HCI) has been delivered in New South Wales (NSW), Australia, since 2011 to support implementation of childhood obesity prevention programs at scale. Consequently, a system to support local implementation and data collection, analysis and reporting at local and state levels was necessary. The Population Health Information Management System (PHIMS) was developed to meet this need. Design and development: A collaborative and iterative process was applied to the design and development of the system. The process comprised identifying technical requirements, building system infrastructure, delivering training, deploying the system and implementing quality measures. Use of PHIMS: Implementation of PHIMS resulted in rapid data retrieval and reporting against agreed performance measures for the HCI. The system has 150 users who account for the monitoring and reporting of more than 6000 HCI intervention sites (early childhood services and primary schools). Lessons learnt: Developing and implementing PHIMS presented a number of complexities including: applying an information technology (IT) development methodology to a traditional health promotion setting; data access and confidentiality issues; and managing system development and deployment to intended timelines and budget. PHIMS was successfully codesigned as a flexible, scalable and sustainable IT solution that supports state-wide HCI program implementation, monitoring and reporting.

Background and aim: Evaluations of alcohol policy changes demonstrate that restriction of trading hours of both ¿on¿- and ¿off¿-licence venues can be an effective means of reducing rates of alcohol-related harm. Despite this, the effects of different trading hour policy options over time, accounting for different contexts and demographic characteristics, and the common co-occurrence of other harm reduction strategies in trading hour policy initiatives, are difficult to estimate. The aim of this study was to use dynamic simulation modelling to compare estimated impacts over time of a range of trading hour policy options on various indicators of acute alcohol-related harm. Methods: An agent-based model of alcohol consumption in New South Wales, Australia was developed using existing research evidence, analysis of available data and a structured approach to incorporating expert opinion. Five policy scenarios were simulated, including restrictions to trading hours of on-licence venues and extensions to trading hours of bottle shops. The impact of the scenarios on four measures of alcohol-related harm were considered: total acute harms, alcohol-related violence, emergency department (ED) presentations and hospitalizations. Results: Simulation of a 3¿a.m. (rather than 5¿a.m.) closing time resulted in an estimated 12.3¿±¿2.4% reduction in total acute alcohol-related harms, a 7.9¿±¿0.8% reduction in violence, an 11.9¿±¿2.1% reduction in ED presentations and a 9.5¿±¿1.8% reduction in hospitalizations. Further reductions were achieved simulating a 1¿a.m. closing time, including a 17.5¿±¿1.1% reduction in alcohol-related violence. Simulated extensions to bottle shop trading hours resulted in increases in rates of all four measures of harm, although most of the effects came from increasing operating hours from 10¿p.m. to 11¿p.m. Conclusions: An agent-based simulation model suggests that restricting trading hours of licensed venues reduces rates of alcohol-related harm and extending trading hours of bottle shops increases rates of alcohol-related harm. The model can estimate the effects of a range of policy options.

Objective To (i) describe the proportion of foods and beverages available on school canteen menus classified as having high ('green'), moderate ('amber') or low ('red') nutritional value; (ii) describe the proportion of these items purchased by students; and (iii) examine the association between food and beverage availability on school canteen menus and food and beverage purchasing by students.Design A cross-sectional study was conducted as part of a larger randomised controlled trial (RCT).Setting A nested sample of fifty randomly selected government schools from the Hunter New England region of New South Wales, Australia, who had participated in an RCT of an intervention to improve the availability of healthy foods sold from school canteens, was approached to participate.Subjects School principals, canteen managers and students.Results The average proportion of green, amber and red items available on menus was 47·9, 47·4 and 4·7 %, respectively. The average proportion of green, amber and red items purchased by students was 30·1, 61·8 and 8·1 %, respectively. There was a significant positive relationship between the availability and purchasing of green (R 2=0·66), amber (R 2=0·57) and red menu items (R 2=0·61). In each case, a 1 % increase in the availability of items in these categories was associated with a 1·21, 1·35 and 1·67 % increase in purchasing of items of high, moderate and low nutritional value, respectively.Conclusions The findings provide support for school-based policies to improve the relative availability of healthy foods for sale in these settings.

Background: Implementation interventions delivered in schools to improve food provision have been found to improve student diet and reduce child obesity risk. If the health benefits of food availability policies are to be realised, interventions that are effective need to be implemented at scale, across an entire population of schools. This study aims to assess the potential effectiveness of an intervention in increasing the implementation, at scale, of a healthy canteen policy by Australian primary schools. Methods: A non-controlled before and after study was conducted in primary schools located in the Hunter New England region of New South Wales, Australia. Schools received a multi-component intervention adapted from a previous efficacious and cost-effective randomised control trial. The primary trial outcome was the proportion of canteen menus compliant with the state healthy canteen policy, assessed via menu audit at baseline and follow-up by dietitians. Secondary outcomes included policy reach and adoption and maintenance policy implementation. Results: Of the 173 schools eligible for inclusion in the trial, 168 provided menus at baseline and 157 menus were collected at follow-up. At follow-up, multiple imputation analysis found 35% (55/157) of schools compared to 17% (29/168) at baseline (OR = 2.8 (1.6-4.7), p = < 0.001) had menus compliant with the state healthy canteen policy. As an assessment of the impact of the intervention on policy reach, canteen manager and principal knowledge of the policy increased from 64% (n = 76) and 38% (n = 44) respectively at baseline to 69% (n = 89) and 60% (n = 70) at follow-up (p = 0.393, p = 0.026). Adoption of the policy increased from 80% (n = 93) at baseline to 90% (n = 104) at follow-up (p = 0.005) for principals, and from 86% (n = 105) to 96% (n = 124) (p = 0.0001) for canteen managers. Multiple imputation analysis showed intervention effects were maintained six-months post intervention (33% of menus compliant OR = 2.6 (1.5-4.5), p = < 0.001 compared to baseline). Conclusions: This study found school canteen compliance with a healthy food policy increased in association with a multi-strategy intervention delivered at scale. The study provides evidence for public health policy makers and practitioners regarding strategies and modes of support required to support improvement in nutrition policy implementation across entire populations of schools.

Background Front-of-pack graphical nutritional rating of products is becoming an important strategy in many countries to improve healthy food purchases by consumers. Evidence of the effectiveness of such on facilitating healthy food choices by school food service providers has not been reported. The primary aim of the study was to assess the impact of providing front-of-pack nutritional rating information on school canteen managers¿ likely food selections. Secondary outcomes were canteen manager awareness, attitudes and reported barriers to using the front-of-pack information. Methods A randomised controlled trial involving primary school canteen managers was conducted in a single region in New South Wales, Australia. Eligible participants were randomised to an intervention or control group and asked in a telephone interview which of 12 common food products sold in school canteens they would sell. Both groups received product name and brand information. The intervention group also received information regarding the nutritional rating of products. Results Canteen managers in the intervention group were significantly more likely than those in the control group to indicate they would sell three of the six ¿healthier¿ products (p = 0.036, 0.005, 0.009). There was no difference between groups in the likelihood of making available for sale any of the six ¿less healthy¿ products. The majority of canteen managers who had heard of a product nutritional rating system agreed that it was helpful in identifying ¿healthier¿ foods (88%, n = 31). Conclusions The inclusion of product nutritional rating information has the potential to improve the availability of some ¿healthier¿ items on canteen menus and contribute to improving child dietary intake. Further research is required to determine whether the use of product nutritional rating information actually makes a difference to canteen manager choices.

Background: Exploring factors associated with retention in randomised trials provides insight into potential threats to internal and external study validity, and may inform the development of interventions to increase retention in future trials. Given a paucity of existing research in the field, a study was conducted to explore factors associated with retention in a smoking intervention trial involving persons with a mental illness, considering demographic and smoking characteristics, treatment condition and engagement in prior follow-up assessments. Method: A descriptive study was undertaken using data derived from a RCT of a smoking cessation intervention initiated in four adult psychiatric inpatient units in New South Wales (NSW), Australia. Retention assessment was undertaken at 1, 6 and 12-months post-discharge. A Generalised Linear Mixed Model was adopted to explore associations between retention at any follow up time point and demographic and smoking characteristics. Chi square analyses explored the association between retention at all follow up time points and treatment condition, and binary logistic regression analyses assessed for relationships between retention at 12-month follow up and engagement in prior follow up assessments. Results: Retention rates were 63, 56 and 60% at the 1, 6 and 12-month assessments, respectively. No association was found between retention at any follow-up time point and 13 of 15 demographic and smoking characteristics. Younger participants and those who identified to be Aboriginal and/or Torres Strait Islander were more likely to be retained (both ps > 0.05). Retention rates did not vary according to treatment condition at any follow-up time point. Participants who completed a prior assessment were more likely to complete the 12 month assessment (both prior assessments: OR 10.7, p < 0.001; 6 month assessment: OR 6.01, p < 0.001; and 1 month assessment: OR 1.8, p = 0.002). Conclusion: The underrepresentation of younger participants and those identifying to be Aboriginal and/or Torres Strait Islander may limit the generalisability of findings. Findings suggest that inclusion of multiple contacts during a trial follow up period may increase retention at the final assessment. Interventions to improve retention, overall and for those sub-groups less likely to be retained, in smoking trials involving persons with a mental illness are needed. Further assessment of sample characteristics, and also trial design factors, associated with retention in this field is warranted.

This study aimed to report the receipt of smoking care, and associated clinical and smoking characteristics among smokers admitted to four public psychiatric inpatient facilities in New South Wales, Australia. Between October 2012 and July 2014, adult smokers (N¿=¿236) were surveyed during admission to and 1¿month following discharge from the facilities. Measures of smoking care receipt were reported descriptively, and logistic regression analyses were used to explore characteristics associated with care receipt. The majority of participants were offered (78%) and used (78%) nicotine replacement therapy (NRT), with 66% of NRT-users reporting the amount provided was sufficient to reduce cravings. A minority of participants (16%) received information or advice to quit smoking, and 60% reported smoking throughout their admission. Patients not contemplating quitting and those with non-psychotic disorders were more likely to receive an offer of NRT. The findings suggest the provision of smoking care in Australian acute psychiatric units is sub-optimal overall, with an indication that care may be provided selectively to certain patients, rather than systematically to all. Development and dissemination of interventions to increase smoking care provision in inpatient psychiatry are needed.

Objectives: Alcohol misuse is a complex systemic problem. The aim of this study was to explore the feasibility of using a transparent and participatory agent-based modelling approach to develop a robust decision support tool to test alcohol policy scenarios before they are implemented in the real world. Methods: A consortium of Australia¿s leading alcohol experts was engaged to collaboratively develop an agent-based model of alcohol consumption behaviour and related harms. As a case study, four policy scenarios were examined. Results: A 19.5¿±¿2.5% reduction in acute alcohol-related harms was estimated with the implementation of a 3¿a.m. licensed venue closing time plus 1¿a.m. lockout; and a 9¿±¿2.6% reduction in incidence was estimated with expansion of treatment services to reach 20% of heavy drinkers. Combining the two scenarios produced a 33.3¿±¿2.7% reduction in the incidence of acute alcohol-related harms, suggesting a synergistic effect. Conclusions: This study demonstrates the feasibility of participatory development of a contextually relevant computer simulation model of alcohol-related harms and highlights the value of the approach in identifying potential policy responses that best leverage limited resources.

Introduction and Aims: Alcohol misuse and harm are more prevalent amongst sports people than non-sports people. Few studies have trialled interventions to address alcohol misuse for this group. The study aimed to test the effectiveness of an intervention to reduce alcohol misuse and related harms amongst amateur sports people in Ireland. Design and Methods: A controlled trial was conducted in two counties in Ireland. A random selection of sports clubs in one county received a 4 month multi-faceted intervention. All sports clubs in a non-adjacent county acted as control sites. Consumption of more than 21 units of alcohol per week and six or more standard drinks on a single occasion at least once per week was the primary study outcome. Alcohol Use Disorders Identification Test scores and number of alcohol-related harms were also reported. Outcomes were assessed for cross-sectional samples of players at pre-intervention and post-intervention and paired samples of players who completed surveys at both times. Generalised linear mixed model analysis was used. Results: There was no evidence of effect for the primary outcomes or Alcohol Use Disorders Identification Test scores. There was a statistically significant difference in the median number of alcohol-related harms reported by intervention group players compared with control group players at post-intervention for the paired samples [intervention: 0; control: 3; incident rate ratio 0.56 (0.37, 0.84); P = 0.005]. Discussion and Conclusions: Intervention in community sports clubs may be effective in reducing the number of alcohol-related harms. Low levels of intervention participation and inadequate intervention dose are possible reasons for lack of a broader intervention effect. [O'Farrell A, Kingsland M, Kenny S, Eldin N, Wiggers J, Wolfenden L, Allwright S. A multi-faceted intervention to reduce alcohol misuse and harm amongst sports people in Ireland: A controlled trial. Drug Alcohol Rev 2018;37:14¿22].

Cigarette smoking poses significant health burdens for people with mental illness. They die sooner than they should, and smoking is a major contributor to their high rates of morbid chronic physical health conditions and early mortality, compared to the general population. Family carers provide important support to people with mental illness. However, family carers' perspectives of smoking by their family members with mental illness are largely absent from the research literature and from practice, despite smoking rates remaining high and quit rates remaining low for this population. We know little about how family carers are or could be involved in supporting people with mental illness who smoke to stop smoking. This paper aims to provide a discussion of the opportunities for family carers to support their family member's smoking cessation and a discussion of our preliminary research on this topic. From the available literature, it appears that family carers are well placed to support smoking cessation for this population; however, they struggled physically, philosophically, and emotionally with perceived responsibilities involving their family member's smoking and the caring role. They felt isolated and asserted that there was limited support from service providers to assist them. We concluded that family carers are important agents within the person's immediate environment who could help them to improve their smoking cessation success. This suggests also that mental health services and other health service providers could benefit from including family carers in their efforts to support smoking cessation for people with mental illness who smoke.

Introduction and Aims: Health risk behaviours, such as smoking, nutrition and physical inactivity, are significant contributors to chronic disease for people with substance use disorders. This study reports the prevalence of these behaviours amongst substance use treatment clients, their attitudes towards modifying such behaviours and the acceptability of receiving support to do so. Client characteristics associated with risk status and interest in modifying behaviours were examined. Design and Methods: A cross-sectional survey was undertaken with clients of 15 community substance use treatment services within in New South Wales, Australia. Data for the study were collected via computer assisted telephone interviews. Results: Of those contactable and eligible, 386 (71%) clients completed the survey. Clients reported a high prevalence of smoking (80%), insufficient fruit and/or vegetable consumption (89%) and insufficient physical activity (31%). Overall, 51¿69% of clients reported considering modifying their health risk behaviours and 88¿97% thought it was acceptable to be provided preventive care to address such behaviours. Younger clients were more likely to smoke (18¿34 years (odds ratio [OR] = 4.6 [95% confidence interval [CI] = 1.9, 11.3]); 35¿54 years (OR = 2.6 [95% CI = 1.2, 5.7])) and be interested in increasing vegetable consumption (18¿34 years (OR = 4.4 [95% CI = 1.3, 14.8]); 35¿54 years (OR = 8.0 [95% CI = 2.5, 25.4])) than older clients (=55 years). Discussion and Conclusions: There is a high prevalence of health risk behaviours amongst clients of community substance use treatment services. However, contrary to commonly cited barriers to care provision, clients are interested in modifying their risk behaviours and report that receiving preventive care to address these behaviours is acceptable. [Tremain D, Freund M, Wolfenden L, Wye P, Bowman J, Dunlop A, Gillham K, Bartlem K, McElwaine K, Gow B, Wiggers J. Modifiable health risk behaviours and attitudes towards behaviour change of clients attending community-based substance use treatment services. Drug Alcohol Rev 2017;36:369¿377.].

Children attending centre based childcare services consume as much as two thirds of their daily dietary requirements while in care. However, such services often fail to provide foods that are consistent with guideline recommendations. Developing strategies to improve childcare service adherence to menu dietary guidelines requires a comprehensive understanding of factors that may impede or promote implementation. The primary aim of this systematic review is to describe factors (barriers and facilitators) that may influence the implementation of menu dietary guidelines regarding food provision in centre-based childcare services and to map these factors to a theoretical framework. Over 7000 citations were identified from all sources. Duplicate abstracts were removed and selection criteria applied. Twelve studies (1994¿2015) were included in the review. Dual data extraction was conducted and the reported factors were synthesised using the theoretical domains framework (TDF). Barriers and facilitators identified in qualitative studies were classified into 8 and 10 of the 14 TDF domains. Barriers and facilitators reported in quantitative studies covered 6 and 3 TDF domains respectively. The most common domain of which both barriers and facilitators to the implementation of menu dietary guidelines were identified was ¿environmental context and resources¿. This is the first study that comprehensively assesses literature to identify factors that influence the implementation of menu dietary guidelines in childcare services utilising a theoretical framework. Findings provide guidance to support researchers and policy makers design strategies to improve menu dietary guideline implementation and, as such have the potential to improve food provision in care.

Worldwide, 10¿20% of adolescents experience mental health problems. Strategies aimed at strengthening resilience protective factors provide a potential approach for reducing mental health problems in adolescents. This study evaluated the effectiveness of a universal, school-based intervention targeting resilience protective factors in reducing mental health problems in adolescents. A cluster randomised controlled trial was conducted in 20 intervention and 12 control secondary schools located in socio-economically disadvantaged areas of NSW, Australia. Data were collected from 3115 students at baseline (Grade 7, 2011), of whom 2149 provided data at follow up (Grade 10, 2014; enrolments in Grades 7 to 10 typically aged 12¿16 years; 50% male; 69.0% retention). There were no significant differences between groups at follow-up for three mental health outcomes: total SDQ, internalising problems, and prosocial behaviour. A small statistically significant difference in favour of the control group was found for externalising problems. Findings highlight the continued difficulties in developing effective, school-based prevention programs for mental health problems in adolescents. Trial registration ANZCTR (Ref no: ACTRN12611000606987).

People with a mental illness experience greater chronic disease morbidity and mortality compared to those without mental illness. Family carers have the potential to promote the health behaviours of those they care for however factors which may influence the extent to which they do so have not been reported. An exploratory study was conducted to investigate carers': 1) promotion of fruit and vegetable consumption, physical activity, quitting smoking, and reducing alcohol consumption; 2) perceptions of their role and ability to promote such behaviours; 3) and the association between carer perceptions and the promotion of such behaviours. A cross-sectional survey was conducted with mental health carers (N¿=¿144, 37.6% response rate) in New South Wales, Australia in 2013. Associations between current promotion of health behaviours and carer perceptions were explored through multivariate regression analysis in 2016. A majority of respondents promoted fruit and vegetable consumption (63.8%), physical activity (60.3%), quitting smoking (56.3%), and reducing alcohol consumption (56.2%) to the person they cared for. A perception that it was ¿very important¿ to have a positive influence on these behaviours was positively related with promotion of each of the four behaviours, with those holding such a view being more likely to promote such behaviours, than those who did not (odds ratio: 9.47¿24.13, p¿<¿0.001). The majority (56.2%¿63.8%) of carers reported promoting the health behaviours of those they cared for, demonstrating a need and opportunity to build the capacity of carers to contribute to reducing the health risk behaviours among people with a mental illness.

Background: Schools play an important role in physical activity promotion for adolescents. The systematic review aimed to determine the proportion of secondary (middle and high) school physical education (PE) lesson time that students spend in moderate to vigorous physical activity (MVPA), and to assess if MVPA was moderated by school level (middle and high school), type of physical activity measurement and type of PE activities. Methods: A systematic search of nine electronic databases was conducted (PROSPERO2014:CRD42014009649). Studies were eligible if they were published between 2005 and 2014; written in English; assessed MVPA in PE lessons of secondary (middle and high) school students; and used a quantitative MVPA measure (i.e., accelerometry, heart rate monitoring, pedometers or observational measures). Two reviewers examined the retrieved articles, assessed risk of bias, and performed data extraction. Random effects meta-analysis was used to calculate a pooled estimate of the percent of PE lesson time spent in MVPA and to assess moderator effects where data allowed. Results: The search yielded 5,132 potentially relevant articles; 28 articles representing 25 studies (7 middle and 18 high school) from seven countries were included. Twelve studies measured MVPA through observational measures, seven used accelerometers, five used heart rate monitors and four used pedometers (including three studies using a mix of measures). Meta-analysis of 15 studies found that overall, students spent a mean (95% CI) of 40.5% (34.8-46.2%) of PE in MVPA. Middle school students spent 48.6% (41.3-55.9%) of the lesson in MVPA (n=5 studies) and high school students 35.9% (28.3-43.6%) (n=10 studies). Studies measuring MVPA using accelerometers (n=5) showed that students spent 34.7% (25.1-44.4%) of the lesson in MVPA, while 44.4% (38.3-50.5%) was found for lessons assessed via observation (n=9), 43.1% (24.3-61.9%) of the lesson for a heart rate based study, and 35.9% (31.0-40.8%) for a pedometer-measured study. Conclusions: The proportion of PE spent in MVPA (40.5%) is below the US Centre for Disease Control and Prevention and the UK Associations for Physical Education recommendation of 50%. Findings differed according to the method of MVPA assessment. Additional strategies and intervention research are needed to build more active lesson time in PE.

Objective: Interventions are required to redress the disproportionate tobacco-related health burden experienced by persons with a mental illness. This study aimed to assess the efficacy of a universal smoking cessation intervention initiated within an acute psychiatric inpatient setting and continued post-discharge in reducing smoking prevalence and increasing quitting behaviours. Method: A randomised controlled trial was undertaken across four psychiatric inpatient facilities in Australia. Participants (N = 754) were randomised to receive either usual care (n = 375) or an intervention comprising a brief motivational interview and self-help material while in hospital, followed by a 4-month pharmacological and psychosocial intervention (n = 379) upon discharge. Primary outcomes assessed at 6 and 12 months post-discharge were 7-day point prevalence and 1-month prolonged smoking abstinence. A number of secondary smoking-related outcomes were also assessed. Subgroup analyses were conducted based on psychiatric diagnosis, baseline readiness to quit and nicotine dependence. Results: Seven-day point prevalence abstinence was higher for intervention participants (15.8%) than controls (9.3%) at 6 months post-discharge (odds ratio = 1.07, p = 0.04), but not at 12 months (13.4% and 10.0%, respectively; odds ratio = 1.03, p = 0.25). Significant intervention effects were not found on measures of prolonged abstinence at either 6 or 12 months post-discharge. Differential intervention effects for the primary outcomes were not detected for any subgroups. At both 6 and 12 months post-discharge, intervention group participants were significantly more likely to smoke fewer cigarettes per day, have reduced cigarette consumption by 3/450% and to have made at least one quit attempt, relative to controls. Conclusions: Universal smoking cessation treatment initiated in inpatient psychiatry and continued post-discharge was efficacious in increasing 7-day point prevalence smoking cessation rates and related quitting behaviours at 6 months post-discharge, with sustained effects on quitting behaviour at 12 months. Further research is required to identify strategies for achieving longer term smoking cessation.

Universal school-based interventions that address adolescent ¿resilience¿ may represent a means of reducing adolescent substance use, however previous systematic reviews have not examined the effectiveness of such an intervention approach. A systematic review was undertaken to 1) assess whether universal school-based ¿resilience¿ interventions are effective in reducing the prevalence of tobacco, alcohol or illicit substance use by adolescents, and 2) describe such effectiveness per intervention characteristic subgroups. Eligible studies were peer-reviewed reports (1994¿2015) of randomised controlled trials including participants aged 5¿18¿years that reported adolescent tobacco, alcohol or illicit substance use, and implemented a universal school-based ¿resilience¿ intervention (i.e. those addressing both individual (e.g. self-esteem) and environmental (e.g. school connectedness) protective factors of resilience). Trial effects for binary outcomes were synthesised via meta-analyses and effect sizes reported as odds ratios. Subgroup (by intervention type, prevention approach, setting, intervention duration, follow-up length) and sensitivity analyses (excluding studies at high risk of bias) were conducted. Nineteen eligible studies were identified from 16,619 records (tobacco: n¿=¿15, alcohol: n¿=¿17, illicit: n¿=¿11). An overall intervention effect was found for binary measures of illicit substance use (n¿=¿10; OR: 0.78, 95%CI: 0.6¿0.93, p¿=¿0.007,Tau2¿=¿0.0, I2¿=¿0%), but not tobacco or alcohol use. A similar result was found when studies assessed as high risk of bias were excluded. Overall intervention effects were evident for illicit substance use within multiple intervention characteristic subgroups, but not tobacco and alcohol. Such results support the implementation of universal school-based interventions that address ¿resilience¿ protective factors to reduce adolescent illicit substance use, however suggest alternate approaches are required for tobacco and alcohol use. PROSPERO registration: CRD42014004906.

Objectives: To investigate patterns of alcohol use within the coal mining industry, and associations with the personal, social, workplace and employment characteristics. Design: 8 mine sites across 3 eastern Australian states were surveyed, selected to encompass key geographic characteristics (accessibility and remoteness) and mine type (open cut and underground). Problematic alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT) to determine: (1) overall risky or hazardous drinking behaviour; and (2) frequency of single-occasion drinking (6 or more drinks on 1 occasion). Results: A total of 1457 employees completed the survey, of which 45.7% of male and 17.0% of female participants reported levels of alcohol use within the range considered as risky or hazardous, considerably higher than the national average. Hierarchical linear regression revealed a significant contribution of many individual level factors associated with AUDIT scores: younger age, male, current smoking status; illicit substance use; previous alcohol and other drug use (AOD) problems; and higher psychological distress. Workplace factors associated with alcohol use included working in mining primarily for the high remuneration, and the type of mining, with underground miners reporting higher alcohol use than open-cut miners. Conclusions: Our findings provide support for the need to address alcohol use in the coal mining industry over and above routine on-site testing for alcohol use.

Introduction: The prevalence of smoking among persons with a mental illness has remained unchanged, being 2-3 times higher than the general population in high-income countries. Assessment of the volume and characteristics of research output over time can assist in identifying research priorities to promote progress within a field. The aim of this study was to undertake such an assessment in the field of smoking and mental illness. Methods: A descriptive repeat cross-sectional study was conducted of peer-reviewed publications in Medline and PsycINFO for the periods 1993-1995, 2003-2005, and 2013-2015. Publications were classified as data- or non-data-based; data-based publications were further categorized by study type, population, setting, and for intervention-focused publications by level of evidence and research translation phase. Results: Included were 547 articles published in 1993-1995 (n = 65), 2003-2005 (n = 153), and 2013-2015 (n = 329). The number and proportion of data-based publications significantly increased over time, although their focus remained predominantly descriptive (=83%); less than 14% of publications in any period had an intervention focus. The proportion of publications reporting on study populations with multiple diagnostic categories and recruiting from nonmental health settings, significantly increased from 1993-1995 to 2003-2005, however then plateaued by 2013-2015. The level of evidence provided by intervention-focused publications was suggested to increase over time, however there was no evident variation in translation phase. Conclusions: Research has increased over time to characterize smoking among those with a mental illness; however more is needed to inform the development and implementation of effective cessation interventions for this group. Implications: This is the first study to examine the volume and characteristics of research publications in the field of smoking and mental illness over time. The number of publications increased fivefold between 1993-1995 and 2013-2015. Between 1993-1995 and 2003-2005, progression was also indicated by increased: data-based publications, diagnostic diversity of samples, and variation in study settings; however further increases in such measures were not evident in 2013-2015. Notably, it continues to be the case that few intervention studies are undertaken. To achieve meaningful changes in the smoking prevalence of this group, a greater focus on research that assesses the effectiveness and implementation of tailored cessation interventions is required.

Objective To examine the effect of universal, school-based, resilience-focused interventions on mental health problems in children and adolescents. Method Eligible studies were randomized controlled trials (RCTs) of universal, school-based interventions that included strategies to strengthen a minimum of 3 internal resilience protective factors, and included an outcome measure of mental health problems in children and adolescents aged 5 to 18 years. Six databases were searched from 1995 to 2015. Results were pooled in meta-analyses by mental health outcome (anxiety symptoms, depressive symptoms, hyperactivity, conduct problems, internalizing problems, externalizing problems, and general psychological distress), for all trials (5-18 years). Subgroup analyses were conducted by age (child: 5-10 years; adolescent: 11-18 years), length of follow-up (short: post-=12 months; long: >12 months), and gender (narrative). Results A total of 57 included trials were identified from 5,984 records, with 49 contributing to meta-analyses. For all trials, resilience-focused interventions were effective relative to a control in reducing 4 of 7 outcomes: depressive symptoms, internalizing problems, externalizing problems, and general psychological distress. For child trials (meta-analyses for 6 outcomes), interventions were effective for anxiety symptoms and general psychological distress. For adolescent trials (meta-analyses for 5 outcomes), interventions were effective for internalizing problems. For short-term follow-up, interventions were effective for 2 of 7 outcomes: depressive symptoms and anxiety symptoms. For long-term follow-up (meta-analyses for 5 outcomes), interventions were effective for internalizing problems. Conclusion The findings may suggest most promise for using universal resilience-focused interventions at least for short-term reductions in depressive and anxiety symptoms for children and adolescents, particularly if a cognitive-behavioral therapy-based approach is used. The limited number of trials providing data amenable for meta-analysis for some outcomes and subgroups, the variability of interventions, study quality, and bias mean that it is not possible to draw more specific conclusions. Identifying what intervention qualities (such as number and type of protective factor) achieve the greatest positive effect per mental health problem outcome remains an important area for future research. Systematic review protocol and registration Systematic Review of Universal Resilience Interventions Targeting Child and Adolescent Mental Health in the School Setting; http://dx.doi.org/10.1186/s13643-015-0172-6; PROSPERO CRD42015025908.

Issue addressed: This study of primary school principals assessed the awareness, use, barriers to use and acceptability of online canteens. Methods: A telephone survey of 123 primary school principals within the Hunter New England Region of New South Wales, Australia was conducted from September 2014 to November 2014. Results: Fifty-six percent of principals were aware of the existence of online canteens, with 8% having implemented such a system, and 38% likely to do so in the future. Medium/large schools were more likely to be aware of or to use online canteens, however there were no differences in awareness or use in relation to school rurality or socioeconomic advantage. Principals cited parent internet access as the most commonly identified perceived barrier to online canteen use, and the majority of principals (71-93%) agreed that it would be acceptable to implement a range of consumer behaviour strategies via an online canteen. Conclusions: Study findings suggest that despite relatively low levels of current use, online canteens have the potential to reach a large proportion of school communities in the future, across geographical and socioeconomic divides, and that the nutrition interventions which they have the capacity to deliver are considered acceptable to school principals. So what? Online canteens may represent an opportunity to deliver nutrition interventions to school communities. Future research should examine the feasibility and potential effectiveness of interventions delivered via this modality.

Issue addressed Universities represent important settings for the implementation of public health initiatives such as smoke-free policies. The study aimed to assess staff and student attitudes towards policy enforcement and compliance as well as the acceptability of the provision of cessation support in this setting. Methods A cross-sectional study was conducted following the introduction of a designated-areas partial smoke-free policy at two campuses of one Australian university in 2014. Staff (n=533) and students (n=3060) completed separate online surveys assessing attitudes towards smoke-free policy enforcement and compliance, and acceptability of university-provided cessation support. Results Students held significantly stronger beliefs than staff that the smoke-free policy required staff enforcement (69% vs 60%) and violation penalties (67% vs 60%; both P's <0.01); however, most staff (66%) did not believe enforcement was part of their role. Only 55% of student smokers were aware that the university provided any cessation support. 'Free or cheap nicotine replacement therapy' (65%) and 'free stop smoking counselling service' (60%) were the most popular strategies student smokers thought the university should provide. Conclusions University staff and students hold conflicting views over the need for policy enforcement and who is responsible for enforcement roles. Students view the university as an acceptable setting for the provision of smoking cessation support. So what? Where staff are expected to enforce smoke-free policies, specific education and training should be provided. Ongoing monitoring of compliance and enforcement behaviour appears necessary to avoid the pervasive kind of non-compliance to smoke-free policies that have been seen in other settings.

Background Exposure to secondhand smoke (SHS) is a significant contributor to ill health in children. A study was undertaken to determine the effectiveness of two brief multi-strategic child health nurse delivered interventions in: decreasing the prevalence of infants exposed to SHS; decreasing the prevalence of smoking amongst parent/carers of infants and increasing the prevalence of household smoking bans. Methods This study was a 3 arm, cluster randomised controlled trial. Clusters were 39 community based well child health clinics in one local area health service. Clinics were stratified according to annual number of client appointments and then randomly assigned in a 1:1:1 ratio, (Intervention 1: Intervention 2: Control), with 13 clinics in each cluster. Parents/carers of infants in the intervention groups received a brief multi-strategic intervention from child health nurses during clinic consultations. Treatment condition¿1 included computer delivered risk assessment and feedback and nurse brief advice. Treatment condition¿2 included all elements of Treatment condition¿1 with the addition of biochemical feedback of infant SHS exposure. Results When compared to the Control group at 12¿months, no significant differences in the prevalence of infant exposure to SHS were detected from baseline to follow-up for Treatment condition¿1 (OR 1.16, 95¿% CI 0.73¿1.85, p¿=¿0.53) or Treatment condition¿2 (OR 1.30, 95¿% CI 0.88¿1.92, p¿=¿0.19) Similarly, no significant differences were detected in the proportion of parent/carers who reported that they were smokers (T1:OR 0.95, 95¿% CI 0.78¿1.15, p¿=¿0.58 and T2:OR 0.97, 95¿% CI 0.80¿1.18, p¿=¿0.77), or in the proportion of households reported to have a complete smoking ban (T1:OR 1.21, 95¿% CI 0.89¿1.64, p¿=¿0.23 and T2:OR 1.06, 95¿% CI 0.79¿1.43, p¿=¿0.68). Conclusions Further research is required to identify effective interventions that can be consistently provided by child health nurses if the potential of such settings to contribute to reductions in child SHS exposure is to be realised.

Context: The review describes the effectiveness of physical activity interventions implemented in centre-based childcare services and (i) examines characteristics of interventions that may influence intervention effects; (ii) describes the effects of pragmatic interventions and non-pragmatic interventions; (iii) assesses adverse effects; and (iv) describes cost-effectiveness of interventions Methods: Data sources were Cochrane Central Register of Controlled trials, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, SCOPUS and SPORTDISCUS. Studies selected included randomized controlled trials conducted in centre-based childcare including an intervention to increase objectively measured physical activity in children aged less than 6years. Data were converted into standardized mean difference (SMD) and analysed using a random effects model. Results: Overall interventions significantly improved child physical activity (SMD 0.44; 95% confidence interval [CI]: 0.12-0.76). Significant effects were found for interventions that included structured activity (SMD 0.53; 95% CI: 0.12-0.94), delivery by experts (SMD 1.26; 95% CI: 0.20-2.32) and used theory (SMD 0.76; 95% CI: 0.08-1.44). Non-pragmatic (SMD 0.80; 95% CI: 0.12-1.48) but not pragmatic interventions (SMD 0.10; 95% CI:-0.13-0.33) improved child physical activity. One trial reported adverse events, and no trials reported cost data. Conclusions: Intervention effectiveness varied according to intervention and trial design characteristics. Pragmatic trials were not effective, and information on cost and adverse effects was lacking. Evidence gaps remain for policymakers and practitioners regarding the effectiveness and feasibility of childcare-based physical activity interventions.

Background: Schools provide opportunities for parents and the wider community to connect and support the physical and emotional wellbeing of their children. Schools therefore have the potential to play a role in the socialisation of alcohol use through school policies and practices regarding consumption of alcohol by adults at school events in the presence of children. Methods: This survey was undertaken to a) compare the extent to which alcohol is used at secondary school events, when children are present, in the states of New South Wales (NSW) and Victoria (VIC), Australia; b) describe principals' level of agreement with these practices; c) their awareness of state policies on this issue; and d) the predictors of such events. A random sample of secondary schools, stratified to represent metropolitan and non-metropolitan schools were invited to participate. Bivariate and multivariate analysis were conducted with p values < 0.05 considered significant. Results: A total of 241 (43 %) schools consented to participate in the study. Fifteen percent of participating NSW schools and 57 % of VIC schools held at least one event in which alcohol was consumed by adults in the presence of children in the year before the survey. Of the 100 reported events, 78 % were Year 12 graduation dinners, and 18 % were debutante balls. Compared to NSW principals, VIC principals were significantly more likely to agree with the use of alcohol at these events; significantly less likely to be aware of their state education department policy on this issue; have a policy at their own school or support policy that prohibits alcohol use at such events; and less likely to report having enough information to make decisions about this. Conclusions: There is a growing focus on adults' use of alcohol at school events when children are present. Schools can play an important role in educating and socialising children about alcohol via both the curriculum and policies regarding adults' alcohol use at school events. Findings from this study suggest education department and school-based policies that prohibit or restrict the use of alcohol, are significant predictors of adults' alcohol use at school events when children are present.

Objective: To thematically synthesise primary qualitative studies of the barriers, motivators and enablers of smoke-free homes (SFHs). Design: Systematic review and thematic synthesis. Data sources: Searches of MEDLINE, EBM Reviews (Cochrane Database of Systematic Reviews), PsycINFO, Global Health, CINAHL, Web of Science, Informit and EMBASE, combining terms for families, households and vulnerable populations; SFH and secondhand smoke; and qualitative research, were supplemented by searches of PhD theses, key authors, specialist journals and reference lists. Study selection: We included 22 articles, reporting on 18 studies, involving 646 participants. Inclusion criteria: peer-reviewed; English language; published from 1990 onwards (to week 3 of April 2014); used qualitative data collection methods; explored participants' perspectives of home smoking behaviours; and the barriers, motivators and enablers to initiating and/or maintaining a SFH. Data extraction: 1 of 3 authors extracted data with checking by a second. Data synthesis: A thematic synthesis was performed to develop 7 core analytic themes: (1) knowledge, awareness and risk perception; (2) agency and personal skills/attributes; (3) wider community norms and personal moral responsibilities; (4) social relationships and influence of others; (5) perceived benefits, preferences and priorities; (6) addiction and habit; (7) practicalities. Conclusions: This synthesis highlights the complexity faced by many households in having a SFH, the practical, social, cultural and personal issues that need to be addressed and balanced by households, and that while some of these are common across study settings, specific social and cultural factors play a critical role in shaping household smoking behaviours. The findings can inform policy and practice and the development of interventions aimed at increasing SFHs.

Background: Preventive care for chronic disease risk behaviours by mental health clinicians is sub-optimal. Little research has examined the association between clinician attitudes and such care delivery. This study aimed to explore: i) the attitudes of a multi-disciplinary group of community mental health clinicians regarding their perceived role, perception of client interest, and perceived self-efficacy in the provision of preventive care, ii) whether such attitudes differ by professional discipline, and iii) the association between these attitudes and clinician provision of such care. Method: A telephone survey was conducted with 151 Australian community mental health clinicians regarding their attitudes towards provision of assessment, advice and referral addressing smoking, nutrition, alcohol, and physical activity, and their reported provision of such care. Logistic regression was used to examine the association between attitudes and care delivery, and attitudinal differences by professional discipline. Results: Most clinicians reported that: their manager supported provision of preventive care; such care was part of their role; it would not jeopardise their practitioner-client relationships, clients found preventive care acceptable, and that they had the confidence, knowledge and skills to modify client health behaviours. Half reported that clients were not interested in changing their health behaviours, and one third indicated that the provision of preventive care negatively impacted on time available for delivery of acute care. The following attitudes were positively associated with the provision of preventive care: role congruence, client interest in change, and addressing health risk behaviours will not jeopardise the client-clinician relationship. Conclusions: Strategies are required to translate positive attitudes to improved client care and address attitudes which may hinder the provision of preventive care in community mental health.

Background: Primary care nurses and allied health clinicians are potential providers of opportunistic preventive care. This systematic review aimed to summarise evidence for the effectiveness of practice change interventions in increasing nurse or allied health professional provision of any of five preventive care elements (ask, assess, advise, assist, and/or arrange) for any of four behavioural risks (smoking, inadequate nutrition, alcohol overconsumption, physical inactivity) within a primary care setting. Methods: A search of Medline, Embase, PsycInfo, and CINAHL databases was undertaken to locate controlled intervention trials published between 1992 and May 2014 that provided practice change interventions to primary care nurses and/or allied health professionals to increase preventive care. The effect of interventions aimed at increasing the provision of any of the five care elements for any of the four behavioural risks was examined. A narrative synthesis was utilised. Results: From 8109 articles, seven trials met the inclusion criteria. All trials bar one, assessed multi-strategic practice change interventions (three to five strategies) focused on care by nurses (six trials) or mixed nursing/allied health clinicians. One trial examined care provision for all four risks, five trials examined care for smoking only, and one trial examined care for alcohol consumption only. For the six trials reporting significance testing (excludes one smoking care trial), significant effects favouring the intervention group were reported in at least one trial for smoking risk assessment (2/4 trials reported an effect for at least one analysis of an assessment outcome), brief advice (2/3), assistance (2/2), and arranging referral (2/3); alcohol risk assessment (1/2) and brief advice (1/2); inadequate nutrition risk assessment (1/1); and physical inactivity risk assessment and brief advice (1/1). When the number of analyses undertaken within trials focusing on smoking care was considered, the results were less promising (e.g. of the 15 analyses conducted on brief advice variables across three trials, four showed a positive effect). Conclusions: Evidence for the effect of practice change interventions on preventive care by primary care nurses or allied health providers is inconclusive given the small number of trials and inconsistency of results between and within trials. Systematic review registration number: None.

© Published by the BMJ Publishing Group Limited.Objective Parents, schools and the broader community influence children's socialisation to alcohol. In Australia, the UK and the USA, there have been media reports of adults consuming alcohol at family-focused school events such as fairs and graduations. The aim of this qualitative study was to describe school principals' experiences of adults' use of alcohol at school events, when children are present. Design/setting/participants A qualitative study was undertaken. Publicly available lists were used to invite 60 principals from government and Catholic secondary schools in Victoria, Australia. In-depth interviews were conducted and analysed thematically and reported using the Consolidated Criteria for Reporting Qualitative Research guidelines. Results 14 principals (5 female, 9 male) participated. Most (10) of the participating principals reported adults' use of alcohol at events when students were present. Regarding these events, most principals reported concerns regarding potential harms and responsibility for decision-making about alcohol availability in schools. Some (4) principals believed alcohol should not be present at such events and this was their practice. Half of the participating schools had recently made changes to reduce the availability or management of alcohol at school functions. Conclusions The findings confirm the common use of alcohol by adults at school events, the challenges this poses for school principals and suggests consideration needs to be given to identifying strategies for supporting schools and school principals in decision-making regarding the conduct of such events.

Background: Few school-based interventions have been successful in reducing physical activity decline and preventing overweight and obesity in adolescent populations. As a result, few cost effectiveness analyses have been reported. The aim of this paper is to report the cost and cost effectiveness of the Physical Activity 4 Everyone (PA4E1) intervention which was a multi-component intervention implemented in secondary schools located in low-income communities. Cost effectiveness was assessed using both the physical activity and weight status trial outcomes. Methods: Intervention and Study Design: The PA4E1 cluster randomised controlled trial was implemented in 10 Australian secondary schools (5 intervention: 5 control) and consisted of intervention schools receiving seven physical activity promotion strategies and six additional strategies that supported school implementation of the intervention components. Costs associated with physical activity strategies, and intervention implementation strategies within the five intervention schools were estimated and compared to the costs of usual physical activity practices of schools in the control group. The total cost of implementing the intervention was estimated from a societal perspective, based on the number of enrolled students in the target grade at the start of the intervention (Grade 7, n = 837). Economic Outcomes: The economic analysis outcomes were cost and incremental cost effectiveness ratios for the following: minutes of moderate-to-vigorous physical activity (MVPA) per day gained, MET hours gained per person/day; Body Mass Index (BMI) unit avoided; and 10 % reduction in BMI z-score. Results: The intervention cost AUD $329,952 over 24 months, or AUD$394 per student in the intervention group. This resulted in a cost effectiveness ratio of AUD$56 ($35-$147) per additional minute of MVPA, AUD$1 ($0.6-$2.7) per MET hour gained per person per day, AUD$1408 ($788-$6,570) per BMI unit avoided, and AUD$563 ($282-$3,942) per 10 % reduction in BMI z-score. Conclusion: PA4E1 is a cost effective intervention for increasing the physical activity levels and reducing unhealthy weight gain in adolescence, a period in which physical activity typically declines. Additional modelling could explore the potential economic impact of the intervention on morbidity and mortality. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12612000382875.

The aim of this study was to describe the research output and citation rates (academic impact) of public health dissemination and implementation research according to research design and study type. A cross sectional bibliographic study was undertaken in 2013. All original data-based studies and review articles focusing on dissemination and implementation research that had been published in 10 randomly selected public health journals in 2008 were audited. The electronic database ¿Scopus¿ was used to calculate 5-year citation rates for all included publications. Of the 1648 publications examined, 216 were original data-based research or literature reviews focusing on dissemination and implementation research. Of these 72% were classified as descriptive/epidemiological, 26% were intervention and just 1.9% were measurement research. Cross-sectional studies were the most common study design (47%). Reviews, randomized trials, non-randomized trials and decision/cost-effectiveness studies each represented between 6 and 10% of all output. Systematic reviews, randomized controlled trials and cohort studies were the most frequently cited study designs. The study suggests that publications that had the greatest academic impact (highest citation rates) made up only a small proportion of overall public health dissemination and implementation research output.

Introduction: People with substance use problems have a higher prevalence of modifiable health risk behaviors. Routine clinician provision of preventive care may be effective in reducing such health behaviors. This study aimed to examine clinician provision of preventive care to clients of community substance use treatment services. Methods: A cross-sectional survey was undertaken with 386 clients and 54 clinicians of community substance use treatment services in one health district in New South Wales, Australia. Client- and clinician-reported provision of three elements of care (assessment, brief advice and referral) for three health risk behaviors (tobacco smoking, insufficient fruit and/or vegetable consumption and insufficient physical activity) was assessed, with associations with client characteristics examined. Results: Provision was highest for tobacco smoking assessment (90% client reported, 87% clinician reported) and brief advice (79% client reported, 80% clinician reported) and lowest for fruit and vegetable consumption (assessment 23%, brief advice 25%). Few clients reported being offered a referral (<. 10%). Assessment of physical activity and brief advice for all behaviors was higher for clients residing in rural/remote areas. Conclusion: Assessment and brief advice were provided to the majority of clients for smoking, but sub-optimally for the other behaviors. Further investigation of barriers to the provision of preventive care within substance use treatment settings is required, particularly for referral to ongoing support.

In Australia and New Zealand, population groups who experience social disadvantage smoke at much higher rates than the general population. As there are limited data specific to these groups regarding the success of nicotine replacement therapy for smoking cessation, this commentary will provide an overview of the relevant international literature supplemented with observational data relevant to the policy contexts in Australia and New Zealand. [Paul C, Wolfenden L, Tzelepis F, Yoong S, Bowman J, Wye P, Sherwood E, Rose S, Wiggers J. Nicotine replacement therapy as a smoking cessation aid among disadvantaged smokers: What answers do we need? Drug Alcohol Rev 2016;35:785¿789].

© Australian Health Promotion Association 2016.Issue addressed The aim of this study was to assess the impact of an alcohol management intervention on community sporting club revenue (total annual income) and membership (number of club players, teams and spectators). Methods The study employed a cluster randomised controlled trial design that allocated clubs either an alcohol accreditation intervention or a control condition. Club representatives completed a scripted telephone survey at baseline and again ~3 years following. Demographic information about clubs was collected along with information about club income. Results Number of players and senior teams were not significantly different between treatment groups following the intervention. The intervention group, however, showed a significantly higher mean number of spectators. Estimates of annual club income between groups at follow-up showed no significant difference in revenue. Conclusions This study found no evidence to suggest that efforts to reduce alcohol-related harm in community sporting clubs will compromise club revenue and membership. So what? These findings suggest that implementation of an intervention to improve alcohol management of sporting clubs may not have the unintended consequence of harming club viability.

Bridging the gap between research-based evidence and public health policy and practice is a considerable challenge to public health improvement this century, requiring a rethinking of conventional approaches to health research production and use. Traditionally the process of research translation has been viewed as linear and unidirectional, from epidemiological research to identify health problems and determinants, to efficacy and effectiveness trials and studies of strategies to maximise the implementation and dissemination of evidence-based interventions in practice. A criticism of this approach is the considerable time it takes to achieve translation of health research into practice. Hybrid evaluation designs provide one means of accelerating the research translation process by simultaneously collecting information regarding intervention impacts and implementation and dissemination strategy. However, few health promotion research trials employ such designs and often fail to report information to enable assessment of the feasibility and potential impact of implementation and dissemination strategies. In addition to intervention effects, policy makers and practitioners also want to know the impact of implementation strategies. This commentary will define the three categories of effectiveness-implementation hybrid designs, describe their application in health promotion evaluation, and discuss the potential implications of more systematic use of such designs for the translation of health promotion and evaluation.So what?Greater use of effectiveness-implementation hybrid designs may accelerate research translation by providing more practice- and policy-relevant information to end-users, more quickly.

IMPORTANCE Reducing child exposure to tobacco smoke is a public health priority. Guidelines recommend that health care professionals in child health settings should address tobacco smoke exposure (TSE) in children. OBJECTIVE To determine the effectiveness of interventions delivered by health care professionals who provide routine child health care in reducing TSE in children. DATA SOURCES A secondary analysis of 57 trials included in a 2014 Cochrane review and a subsequent extended searchwas performed. Controlled trials (published through June 2015) of interventions that focused on reducing child TSE, with no restrictions placed on who delivered the interventions,were identified. Secondary data extractionwas performed in August 2015. STUDY SELECTION Controlled trials of routine child health care delivered by health care professionals (physicians, nurses, medical assistants, health educators, and dieticians) that addressed the outcomes of interest (TSE reduction in children and parental smoking behaviors) were eligible for inclusion in this review and meta-Analysis. DATA EXTRACTION AND SYNTHESIS Study details and quality characteristicswere independently extracted by 2 authors. If outcome measures were sufficiently similar, meta-Analysis was performed using the random-effects model by DerSimonian and Laird. Otherwise, the results were described narratively. MAIN OUTCOMES AND MEASURES The primary outcome measurewas reduction in child TSE. Secondary outcomes of interest were parental smoking cessation, parental smoking reduction, and maternal postpartum smoking relapse prevention. RESULTS Sixteen studiesmet the selection criteria. Narrative analysis of the 6 trials that measured child TSE indicated no intervention effects relative to comparison groups. Similarly, meta-Analysis of 9 trials that measured parental smoking cessation demonstrated no overall intervention effect (n = 6399) (risk ratio 1.05; 95%CI, 0.74-1.50; P = .78). Meta-Analysis of the 3 trials that measured maternal postpartum smoking relapse prevention demonstrated a significant overall intervention effect (n = 1293) (risk ratio 1.53; 95%CI, 1.10-2.14; P = .01). High levels of study heterogeneity likely resulted from variability in outcome measures, length of follow up, intervention strategies, and unknown intervention fidelity. CONCLUSIONS AND RELEVANCE Interventions delivered by health care professionals who provide routine child health care may be effective in preventing maternal smoking relapse. Further research is required to improve the effectiveness of such interventions in reducing child TSE and increasing parental smoking cessation. The findings of this meta-Analysis have policy and practice implications relating to interventions by routine pediatric health care professionals that aim to reduce child exposure to tobacco smoke.

Aim: This study aimed to assess the impact of including healthier options on fast food restaurant menus on total energy of parent-reported intended purchases and frequency to eat at fast food outlets for young children. Methods: Parents from an existing health survey cohort were approached to participate. They were eligible to participate if they resided in the Hunter region in NSW, could understand English and had a child aged between 3 and 12 years. Parents were randomised using a random number function embedded in the computer assisted telephone interview software, to receive one of two hypothetical fast food menus: one with healthier options and the other without healthier options (standard menu). After receiving these menus, participants completed a second telephone survey. Parents reported intended food purchases for their nominated child and intended number of visits to the fast food outlet with the hypothetical menu. Results: There was no significant difference in total energy of parent-reported intended purchases for their child, between the standard menu with (n = 101) and without (n = 113) healthier options (P = 0.60). There was also no difference in the frequency of intending to eat at the fast food restaurant between the two groups (P = 0.80). Conclusions: The provision of healthier options in itself may not reduce the total energy of intended purchases of parents for young children at fast food restaurants.

Objective: To examine elementary school students' moderate-to-vigorous physical activity (MVPA) levels during physical education (PE) lessons. Methods: A systematic search of nine electronic databases was conducted (PROSPERO2014:CRD42014009649). Studies were eligible if they were in English; published between 2005-April 2014; assessed MVPA levels in PE lessons of elementary school children (aged four-12 years); and used an objective MVPA measure. Two reviewers retrieved articles, assessed risk of bias, and performed data extraction. The findings were synthesised using a meta-analysis. Results: The search yielded 5132 articles. Thirteen studies from nine countries met the inclusion criteria. Eight studies measured MVPA through observational measures, five used accelerometry and one used heart rate monitoring. The percentage of PE lesson time spent in MVPA ranged between 11.4-88.5%. Meta-analysis of seven studies (direct observations; 4 accelerometers) found that children spent a mean (95% CI) 44.8 (28.2-61.4)% of PE lesson time in MVPA. When measured using direct observation and accelerometers, children spent 57.6 (47.3-68.2) and 32.6 (5.9-59.3)% of PE lesson time in MVPA, respectively. The review has limitations; the search strategy was restricted to studies in English; theses, dissertations and conference abstracts were excluded; and six studies that provided insufficient data were excluded from the meta-analysis. Conclusion: MVPA levels during elementary school PE lessons do not meet the United States Centre for Disease Control and Prevention and the United Kingdom's Association of Physical Education recommendation (50% of lesson time), but is higher than estimated in the previous review (34.2%). Interventions to increase MVPA in PE lessons are needed.

The aim of this short report was to describe the output and citation rates of public health. Data-based publications and literature reviews from the year 2008, and their 5-year citation rates were extracted from 10 randomly selected public health journals. In total, 86.2% of publications were descriptive/epidemiological studies, 56.8% used cross-sectional (56.8%) designs and 77.8% were classified as research translation stage 2. Reviews and publications describing randomized controlled trials were the most highly cited, but were infrequently published. Strategies to address the discordance between public health research output and research citation may improve the impact of public health research.

Objective This review aimed to examine the impact of interventions involving an explicit sleep component on child body mass index (BMI), diet, and physical activity. Methods A systematic search was undertaken in six databases to identify randomized controlled trials examining the impact of interventions with a sleep component on child BMI, dietary intake, and/or physical activity. A random effects meta-analysis was conducted assessing the impact of included interventions on child BMI. Results Of the eight included trials, three enforced a sleep protocol and five targeted sleep as part of multicomponent behavioral interventions either exclusively or together with nutrition and physical activity. Meta-analysis of three studies found that multicomponent behavioral interventions involving a sleep component were not significantly effective in changing child BMI (n = 360,-0.04 kg/m2 [-0.18, 0.11], I2 = 0%); however, only one study included in the meta-analysis successfully changed sleep duration in children. There were some reported improvements to adolescent diet, and only one trial examined the impact on child physical activity, where a significant effect was observed. Conclusions Findings from the included studies suggest that where improvements in child sleep duration were achieved, a positive impact on child BMI, nutrition, and physical activity was also observed.

Introduction and Aims: Enforcement of liquor licensing laws is limited by inadequate police information systems. This study aimed to: (i) determine the effectiveness of an intervention in facilitating police recording of the alcohol consumption characteristics of people involved in assaults; and (ii) describe such characteristics by geographic area and setting of alcohol consumption.Design and Methods: A stepped wedge trial was conducted across New South Wales, Australia. An intervention to facilitate police recording of alcohol consumption information for people involved in incidents was implemented. For people involved in an assault the proportion for which alcohol consumption information was recorded was assessed. The proportion of assaults that were alcohol related, the proportions of people that consumed alcohol prior to the assault, were intoxicated, and had consumed alcohol in various settings, are described.Results: Post-intervention, alcohol consumption information was recorded for 85-100% of people involved in an assault incident. The proportion of incidents recorded as alcohol-related increased significantly (26-44.5%; P<0.0001). The proportion of assaults classified as alcohol related was significantly greater in regional/rural areas (50-47%) than in metropolitan areas (38%). More people in metropolitan areas (54%) consumed alcohol on licensed premises prior to an assault than in regional/rural areas (39-42%), with approximately 70% of persons intoxicated regardless of setting of alcohol consumption. Twenty percent of premises accounted for 60% of assaults linked to licensed premises.Discussion and Conclusions: The intervention was effective in enhancing the recording of alcohol-related information for assault incidents. Such information could enhance targeted policing of liquor licensing laws. [Wiggers JH, Hacker A, Kingsland M, Lecathelinais C, Tindall J, Bowman JA, Wolfenden L. Facilitating police recording of the alcohol-related characteristics of assault incidents: A stepped wedge implementation trial. Drug Alcohol Rev 2015;00:000-000].

Psychiatric inpatient settings represent an opportunity to initiate the provision of tobacco cessation care to smokers with a mental illness. This study describes the use of evidence-based smoking cessation aids proactively and universally offered to a population of psychiatric inpatients upon discharge, and explores factors associated with their uptake. Data derived from the conduct of a randomised controlled trial were analysed in terms of the proportion of participants (N¿=¿378) that utilised cessation aids including project delivered telephone smoking cessation counselling and nicotine replacement therapy (NRT), and Quitline support. Factors associated with uptake of cessation aids were explored using multivariable logistic regression analyses. A large proportion of smokers utilised project delivered cessation counselling calls (89¿%) and NRT (79¿%), while 11¿% used the Quitline. The majority accepted more than seven project delivered telephone cessation counselling calls (52¿%), and reported NRT use during more than half of their accepted calls (70¿%). Older age, higher nicotine dependence, irregular smoking and seeing oneself as a non-smoker were associated with uptake of behavioural cessation aids. Higher nicotine dependence was similarly associated with use of pharmacological aids, as was NRT use whilst an inpatient. Most smokers with a mental illness took up a proactive offer of aids to support their stopping smoking. Consideration by service providers of factors associated with uptake may increase further the proportion of such smokers who use evidence-based cessation aids and consequently quit smoking successfully.

Aim: Despite ongoing investments to improve the obesogenic environments of childcare settings, little is known regarding how these services have changed their physical activity and nutrition-promoting practices. This study aims to describe changes in the proportion of Australian childcare services that have adopted best-practice healthy eating and physical activity practices between 2006 and 2013 and to assess whether adoption varied by socio-economic status and locality. Methods: A randomly selected sample of nominated supervisors (n = 358) from childcare services located in New South Wales, Australia, participated in a telephone survey in 2006, 2009, 2010 and 2013. Supervisors reported on their service's adoption of six practices: (i) having written nutrition and physical activity policies; (ii) staff trained in physical activity and nutrition in the past year; (iii) scheduled time for fundamental movement skills and (iv) outdoor play; (v) weekly or less screen time opportunities; and (vi) serving only non-sweetened beverages. Results: A significant increase in the prevalence of services adopting all but one practice, between 2006 and 2013 was identified. Ninety one percent of services adopted four or more practices, a significant increase from 38% in 2006. There were no differences in the proportion of services adopting each practice by locality and socio-economic status. Conclusions: Government investment in obesity prevention programmes can equitably improve childcare service's adoption of healthy eating and physical activity promoting practices on a jurisdiction-wide basis. The establishment of a routine system to monitor adoption of a broader range of practices by childcare services is warranted.

Issue addressed In order to assess the impact of healthy school canteen policies on food availability for students, valid methods of measuring compliance are needed that can be applied at scale. The aim of this study is to assess the validity and direct cost of four methods to assess policy compliance: 1) principal and 2) canteen manager self-report via a computer-assisted telephone interview; and 3) comprehensive and 4) quick menu audits by dietitians, compared with observations. Methods A cross-sectional study took place in the Hunter region of NSW, Australia, in a sample of 38 primary schools that had previously participated in a randomised controlled trial to improve healthy canteen policy compliance. Policy compliance was assessed using the four methods specified above. Percentage agreement, kappa, sensitivity and specificity compared with observations was calculated together with the direct time taken and costs of each method. Indirect costs (including set-up costs) for all measures have not been included. Results Agreement with observations was substantial for the quick menu audit (kappa=0.68), and moderate for the comprehensive menu audit (kappa=0.42). Principal and canteen manager self-report resulted in poor agreement and low specificity with the gold standard. The self-reported measures had the lowest cost, followed by the quick menu audit and lastly the comprehensive menu audit. Conclusion The quick menu audit represents a valid and potentially low-cost method of supporting policy implementation at scale. So what? This study demonstrates that a quick menu audit represents a valid measure of undertaking assessment of school canteen policy compliance at a population level.

Introduction and Aims: Bars, pubs and taverns in cities are often concentrated in entertainment precincts that are associated with higher rates of alcohol-related crime. This study assessed public perception and experiences of such crime in two city entertainment precincts, and support for alcohol-related crime reduction strategies. Design and Methods: A cross-sectional household telephone survey in two Australian regions assessed: perception and experiences of crime; support for crime reduction strategies; and differences in such perceptions and support. Results: Six hundred ninety-four people completed the survey (32%). Most agreed that alcohol was a problem in their entertainment precinct (90%) with violence the most common alcohol-related problem reported (97%). Almost all crime reduction strategies were supported by more than 50% of participants, including visitors to the entertainment precincts, with the latter being slightly less likely to support earlier closing and restrictions on premises density. Participants in one region were more likely to support earlier closing and lock-out times. Those at-risk of acute alcohol harm were less likely to support more restrictive policies. Discussion and Conclusions: High levels of community concern and support for alcohol harm-reduction strategies, including restrictive strategies, provide policy makers with a basis for implementing evidence-based strategies to reduce such harms in city entertainment precincts.

Introduction and Aims: The study investigates the prevalence of pre-drinking culture in the night-time economy (NTE) and its impact upon intoxication and alcohol-related harm and violence experienced by patrons. Design and Methods: Cross-sectional surveys were conducted in and around licensed venues in Newcastle (NSW) and Geelong (Victoria) during peak trading hours (typically 9pm-1am). Participants completed a five minute structured interview which targeted: demographics, past and planned movements on the survey night, safety/experience of harm, and patron intoxication. 3949 people agreed to be interviewed, a response rate of 90.7%. Around half (54.9%) of interviewees were male and mean age was 24.4 years (SD=5.8). Results: 66.8% of participants reported pre-drinking prior to attending licensed venues. On a 1-10 scale measuring self-rated intoxication, pre-drinkers scored significantly higher compared to non pre-drinkers (P<0.001). Compared to non-pre-drinkers, patrons who had consumed 6-10 standard pre-drinks were 1.5 times more likely to be involved in a violent incident in the past 12 months (OR=1.50, 95%CI 1.03-2.19, P=0.037) increasing to 1.8 times more likely for patrons who had 11-15 drinks (OR=1.80, 95%CI 1.04-3.11 P=.036). Pre-drinking was also associated with both self-rated and observer-rated intoxication, as well as increased probability of illicit drug use. Amongst pre-drinkers, price was the most commonly reported motive for pre-drinking (51.8%). Discussion and Conclusions: 'Pre-drinking' was normal behaviour in the current sample and contributes significantly to the burden of harm and intoxication in the NTE. Price disparity between packaged vs. venue liquor is a key motivator for pre-drinking. [Miller P, Droste N, de Groot F, Palmer D, Tindall J, Busija L, Hyder S, Gilham K, Wiggers J. Correlates and motives of pre-drinking with intoxication and harm around licensed venues in two cities.

Objectives: Physical education (PE) plays an important role in contributing to students' physical activity (PA); however, moderate-to-vigorous PA (MVPA) within PE is lower than recommended. Little is known about the PA levels of students from disadvantaged schools within PE. This study aimed to describe: (i) the PA levels of students from disadvantaged secondary schools during PE lessons, (ii) the lesson context and teacher interactions occurring during PE, and (iii) the associations between teacher, school or PE lesson characteristics with student physical activity levels in PE. Design: Cross-sectional study of 100 Grade 7 PE lessons across 10 secondary schools. Methods: System for observing fitness instruction time (SOFIT) was used to assess student PA, lesson context, and teacher interaction. Teacher and school characteristics were collected via survey. Mean proportion of lesson time was used to describe PA, lesson context and teacher interaction. Associations between each outcome variable and each characteristic were examined using 2-sample t-tests, ANOVAs and linear regression. Results: Thirty-nine percent of PE lesson was spent in MVPA, and less than 10% spent in VA. Lessons in schools in urban areas included significantly more MVPA than rural areas (P = 0.04). Male teachers and more experienced teachers conducted lessons with significantly more VA than female and less experienced teachers (P = 0.04 and 0.02). MVPA was also higher in lessons conducted by more experienced teachers. Conclusions: PA during PE lessons within disadvantaged secondary schools is below international recommendations. Male teachers, more experienced teachers and schools in urban regions teach more active lessons.

Background: Adolescence is a recognised period of physical activity decline, particularly among low-income communities. We report the 12-month (midpoint) effects of a 2-year multicomponent physical activity intervention implemented in disadvantaged secondary schools. Methods: A cluster randomised trial was undertaken in 10 secondary schools located in disadvantaged areas in New South Wales, Australia. Students in Grade 7 were recruited, with follow-up in Grade 8. The intervention was guided by socioecological theory and included seven physical activity strategies, and six implementation adoption strategies. The primary outcome was mean minutes of moderate-to-vigorous physical activity (MVPA) per day assessed using Actigraph GT3X accelerometers. Outcome data were analysed using repeated measures linear mixed models. Results: At baseline, 1150 (93%) students participated in the data collection (mean age 12 years, 48% boys) and 1050 (79%) students participated at 12-month follow-up. By the 12-month follow-up, the six implementation adoption strategies had been used to support schools to deliver four of the seven physical activity elements. There was a significant group-by-time interaction for mean minutes of MVPA per day in favour of the intervention group (adjusted difference between groups at follow-up=3.85 min, 95% CI (0.79 to 6.91), p=0.01), including significantly more vigorous physical activity (2.45 min, p=0.01), equating to 27 min more MVPA per week. Summary: At 12-month follow-up, the intervention had reduced the decline in physical activity among adolescents from disadvantaged schools. The intervention may assist students to meet physical activity guidelines.

This is the protocol for a review and there is no abstract. The objectives are as follows: The primary aim of the review is to examine the effectiveness of strategies aimed at improving the implementation by childcare services of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention. The secondary aims of the review are to: describe the impact of such strategies on childcare service staffknowledge, skills or attitudes; describe the cost or cost-effectiveness of such strategies; describe any adverse effects of such strategies on childcare services, service staffor children; examine the effect of such strategies on child diet, physical activity or weight status.

This is the protocol for a review and there is no abstract. The objectives are as follows: The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices that aim to promote healthy or reduce unhealthy behaviours relating to child diet, physical activity, obesity, or tobacco or alcohol use. Secondary objectives of the review are to: examine the effectiveness of implementation strategies on health behavioural (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of stakeholders involved in implementing health promoting policies, programs or practices; describe the cost or cost effectiveness of such strategies; describe any unintended adverse effects of strategies on schools, school staff or children.

© 2015 Dray et al. Background: The mental health of children and adolescents is a key area of health concern internationally. Previous empirical studies suggest that resilience may act as a protective mechanism towards the development of mental health problems. Resilience refers to the ability to employ a collection of protective factors to return to or maintain positive mental health following disadvantage or adversity. Schools represent a potential setting within which protective factors of all children and adolescents may be fostered through resilience-focussed interventions. Despite this potential, limited research has investigated the effectiveness of universal school-based resilience-focussed interventions on mental health outcomes in children and adolescents. The objective of the present review is to assess the effects of universal school-based resilience-focussed interventions, relative to a comparison group, on mental health outcomes in children and adolescents. Methods/design: Eligible studies will be randomised (including cluster-randomised) controlled trials of universal interventions explicitly described as resilience-focussed or comprising strategies to strengthen a minimum of three internal protective factors, targeting children aged 5 to 18 years, implemented within schools, and reporting a mental health outcome. Screening for studies will be conducted across six electronic databases: MEDLINE, PsycINFO, Educational Resources Information Center (ERIC), Excerpta Medica database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials (CENTRAL). Two reviewers will retrieve eligible articles, assess risk of bias, and extract data. Where studies are sufficiently homogenous and reported outcomes are amenable for pooled synthesis, meta-analysis will be performed. Narrative description will be used to synthesise trial outcome data where data cannot be combined or heterogeneity exists. Discussion: This review will aid in building an evidence base for the effectiveness of universal school-based resilience-focussed interventions and in doing so provide an opportunity to better inform the development of interventions to potentially prevent mental health problems in child and adolescent populations. Systematic review registration: PROSPERO CRD42015025908

The implementation of smoke-free policies in inpatient psychiatric facilities, including patient adherence, mental health nursing staff support, and provision of nicotine-dependence treatment to patients, has been reported to be poor. The extent to which the quality of smoke-free policy implementation is associated with patient views of a policy is unknown. We conducted a cross-sectional survey of 181 patients (53.6%, n = 97 smokers; and 46.4%, n = 84 non-smokers) in an Australian inpatient psychiatric facility with a total smoke-free policy. Smokers' adherence to the policy was poor (83.5% smoked). Only half (53.6%) perceived staff to be supportive of the policy. Most smokers used nicotine-replacement therapy (75.3%); although few received optimal nicotine-dependence treatment (19.6%). Overall, 45.9% of patients viewed the smoke-free policy in the unit as positive (29.9% smokers; 64.3% non-smokers). For smokers, adhering to the ban, perceiving staff to be supportive, and reporting that the nicotine-replacement therapy reduced cravings to smoke were associated with a more positive view towards the smoke-free policy. These findings support the importance of patient adherence, mental health nursing staff support, and adequate provision of nicotine-dependence treatment in strengthening smoke-free policy implementation in inpatient psychiatric settings.

Background: Systematic reviews of high-quality evidence are used to inform policy and practice. To improve community health, the production of such reviews should align with burden of disease. This study aims to assess if the volume of research output from systematic reviews proportionally aligns with burden of disease assessed using percentages of mortality and disability-adjusted life years (DALYs). Methods: A cross-sectional audit of reviews published between January 2012 and August 2013 in the Cochrane Database of Systematic Reviews (CDSR) and Database of Abstracts of Reviews of Effects (DARE) was undertaken. Percentages of mortality and DALYs were obtained from the 2010 Global Burden of Disease study. Standardised residual differences (SRD) based on percentages of mortality and DALYs were calculated, where conditions with SRD of more than or less than three were considered overstudied or understudied, respectively. Results: 1029 reviews from CDSR and 1928 reviews from DARE were examined. There was a significant correlation between percentage DALYs and systematic reviews published in CDSR and DARE databases (CDSR: r=0.68, p=0.001; DARE: r=0.60, p < 0.001). There was no significant correlation between percentage mortality and number of systematic reviews published in either database (CDSR: r=0.34, p=0.14; DARE: r=0.22, p=0.34). Relative to percentage of mortality, mental and behavioural disorders, musculoskeletal conditions and other non-communicable diseases were overstudied. Maternal disorders were overstudied relative to percentages of mortality and DALYs in CDSR. Conclusions: The focus of systematic reviews is moderately correlated with DALYs. A number of conditions may be overstudied relative to percentage of mortality particularly in the context of health and medical reviews.

Background: Promotion of healthy eating and physical activity in early childhood is recommended as a global chronic disease prevention strategy. Centre-based childcare services represent a promising setting to provide children with opportunities to improve healthy eating and physical activity. Evidence to inform implementation of childcare obesity prevention guidelines into routine practice in childcare, however, is lacking. This study aims to assess the effectiveness of an intervention, delivered to childcare staff, aiming to increasing service implementation of healthy eating and physical activity-promoting policies and practices. Methods and analysis: A pragmatic parallel group randomised controlled trial will be undertaken with 165 childcare services in the Hunter New England region of New South Wales, Australia. Services will be randomised to receive either a 10-month evidence-based performance review intervention with other resources to support practice change, or to a waitlist control group. The primary trial outcome is the proportion of services implementing all of the following recommended healthy eating and physical activity promoting practices: written nutrition, physical activity and small screen recreation policies; providing information to families regarding healthy eating (including breastfeeding), physical activity and small screen time; providing twice weekly healthy eating learning experiences to children; providing water and only plain milk to children; providing fundamental movement skills activities for children every day; and limiting and using electronic screen time more for educational purposes and learning experiences. Effectiveness will be assessed using a telephone interview of practice implementation with childcare staff at baseline and 12 months following baseline. Ethics and dissemination: The study was approved by the Hunter New England Human Research Ethics Committee and the University of Newcastle Human Research Ethics Committee. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. Trial registration number: Australian New Zealand Clinical Trials Registry ACTRN12614000972628.