Perspectives in Public Health

This study takes a unique approach to understanding the implementation of a whole-system place-based strategy to improve health and reduce health inequalities, using ambidextrous organisational theory.

The data consisted of the secondary analysis of 23 strategy documents in one local authority, and interviews (n = 22) with local decision-makers, front-line workers, and service users.

Our analysis highlights the tensions inherent in British Local Authorities (LAs), which in times of austerity have increasingly been expected to perform as financially self-sufficient, while meeting their health inequalities targets. Increasingly, LAs can be seen as being characterised by goal incoherence, with competing institutional logics. This leads them to exist in a paradoxical reality, leading to ambiguity and unease in the workforce, which can be reconciled through the generation of creative solutions.

Organisations such as LAs can meet both of their social and financial performance ambitions by acknowledging, and working through, simultaneous strategic and operational needs, which capitalise on the potential of both exploration of new solutions and the exploitation of what already works well. Decision-makers need to see goals as not mutually exclusive, and instead engage in strategy discussions that lead to coordinated actions across the full range of ambitions. We highlight the potential contribution of the concept of ambidexterity to help LAs manage their competing priorities. It puts forward the concept of LAs as hybrid organisations with politically appointed boards and professional organisational units that intrinsically manoeuvre between mission and market orientation.

Evidence shows that community group activities can support and improve health and wellbeing. However, research into the patterning of community engagement suggests that socioeconomic factors may act as barriers to participation. Yet, because this research has mainly been conducted in high-income, Western and Global North countries, it remains unclear whether these patterns are consistent across different countries and cultural settings, especially in Global South, low-middle income, and non-Western countries. Further, we do not know whether country-level socioeconomic factors influence community engagement.

Data from 64,065 adult respondents in the World Values Survey were analysed to examine the association between individual-level (education, income, and employment) and country-level (years of compulsory education, GDP per capita, Gini coefficient, and unemployment) socioeconomic factors and community organization membership rates. Multilevel regression modeling was used. Further analyses tested the associations between active membership and various types of community organization memberships. Analyses were adjusted for age, gender, country of birth, household size and marital status.

Prevalence of community organization membership varies across countries. Kenya, Colombia and Mongolia have the highest numbers of memberships and Greece, Russia and Egypt have the lowest numbers. Individual education and perceived household income, and country-level income inequality and employment rate were all positively associated with group membership. Some variations by organisation type were observed.

We found a universal social gradient in community organisation membership, with individual education as the most influential predictor of more memberships across countries. Given that participation in community organizations can improve and support individual and community wellbeing, and plays a role in cultural and social capital development, reducing participatory disparities in these organisations could contribute to the reduction of health and social inequalities.

Encouraging leisure-time physical activity has proved to be a hard-to-solve complex problem. Underpinning this complexity is the range of determinants of sedentary behaviour. We report on a participatory actor mapping exercise which sought to understand the people and organisations in the local system in which a novel exercise referral scheme in a suburban/semi-rural region of England has been introduced.

The participatory actor mapping exercise was conducted in two phases in September 2023. The first phase generated a draft actor map visually illustrating the key organisations and individuals (actors) that make up the local physical activity promotion system. The map was aligned to a socio-ecological model in which actors were positioned within a category of determinants. In the second phase, the draft actor map was refined during two workshops with participants (n = 30) representing the key local organisations who sought to promote physical activity.

The process of mapping revealed several factors influencing physical activity promotion: (1) differing views on the determinants of physical inactivity, and hence, a hesitancy towards addressing sedentary behaviour through a strategic systems approach; (2) an emerging system of actors with interdependent roles which sometimes act independently; (3) local commitment to encouraging increased leisure time activity but supported via a generalised approach to physical activity promotion; and (4) a peripheral role of the studied exercise referral scheme in the system for local physical activity provisions.

The process of a participatory approach to actor mapping highlighted both opportunities and challenges for physical activity promotion. Although there were challenges around differing actors’ perspectives on sedentary behaviour and a lack of connection between actors, opportunities included an improved shared understanding of the complex issues of physical inactivity, and actor mapping provided a useful step towards adopting a systems approach with a common vision.

Despite most school-based food and nutrition programmes improving determinants of healthy eating, most programmes are abandoned within 2 years due to external vulnerabilities in funding and political support. The aim of this study was to explore the enablers and barriers to the implementation and sustainability of Pick of the Crop. Pick of the Crop is a whole-school nutrition programme aimed at increasing opportunities for primary school students to learn about and consume more vegetables and fruit.

Qualitative methods were used for this study. Purposive sampling targeted the recruitment of the Pick of the Crop programme champions from primary schools in three regions of Queensland, Australia (socio-educationally disadvantaged areas; ranging in degree of remoteness). The schools had to be in their third year of implementation. Semi-structured interviews that were informed by the domains of the Consolidated Framework for Implementation Research (CFIR) were conducted with participants. The interviews were transcribed verbatim and coded deductively and inductively. Deductive coding was based on the constructs and sub-constructs of the CFIR, and inductive coding was applied when CFIR constructs were not suitable. The coding informed the development of themes through thematic analysis.

Interviews were conducted with 10 school champions including three principals and seven teachers from across all three regions. Forty-five constructs and 14 sub-constructs of the CFIR were identified, with an additional three inductive codes. Five main themes emerged: (1) implementation facilitators; (2) compatibility with education priorities; (3) generation and use of funding; (4) partnerships and connections with community and (5) programme impact.

To enhance and promote sustainability of the initiative, partnerships between schools and community need to be actively fostered, funding attainment needs to be systematic and programme coordinators play an integral role to supporting Pick of the Crop implementers and their partners.

The Systems Evaluation Network (SEN) aims to build capability and capacity regarding the use of systems science in public health evaluation. The SEN was established in June 2021 and 3 years from its inception, we undertook a member survey to understand the engagement with, and impact of, the SEN.

An 18-item cross-sectional survey captured quantitative and qualitative responses regarding SEN member perspectives, centring around their experience of the SEN, associated impacts, and future requirements. We analysed quantitative data descriptively and qualitative data through content analysis. Sub-group analyses explored differences between those working in academia vs practice/policy.

Seventy-three participants completed the survey, with 60% working in academia and 40% in practice/policy. Considering experiences of the SEN, participants felt the SEN has shared information about innovative methods and evaluation approaches (94.0% agreed), has provided the opportunity to share and learn with other members (86.0% agreed), and has improved knowledge of systems evaluation methods (86.2% agreed). Regarding impacts of the SEN, participants stated that the SEN has increased their capability to apply systems-oriented methods and evaluation of systems approaches (76% agreed) and has facilitated relationships with others (56.9% agreed). Participants shared future capability requirements for evaluation, which focused on methods (e.g. systems dynamics modelling and ripple effects mapping), approaches (e.g. developmental evaluation and embedded researchers), and other ways in which capability could be increased (e.g. by using case studies).

This paper illustrates the experiences and impacts of the SEN, identifying its strengths such as the wide range of topics/content and the flexible and accessible delivery format, but contrast against the difficulties of fostering new relationships in an online setting. These findings can help inform the future direction of the SEN and provide insight to other online communities of practice.

A Joint Strategic Needs Assessment (JSNA) is the process through which health and wellbeing boards in England assess the needs of their local populations to identify inequalities in health and its wider determinants and inform both commissioning priorities and a Joint Local Health and Wellbeing Strategy. We sought to determine how and to what extent JSNAs address the needs of LGBTQ+ people in England.

The local authorities in receipt of a Public Health Grant in 2024 were identified and their websites searched for current (i.e. published in 2020 or later) JSNAs. Those which referenced LGBTQ+ health and wellbeing were assessed against pre-specified methodological and content criteria indicative of LGBTQ+-inclusive practice (e.g. LGBTQ+ community involvement in JSNA development). Counts and percentages described the frequency with which each criterion was met across the eligible JSNAs, and choropleth maps illustrated patterns of inclusion across England.

Of 142 local authorities with an eligible JSNA, 108 referenced LGBTQ+ health and wellbeing at least once. However, few local authorities considered the diversity within LGBTQ+ communities or the impact of intersecting marginalised characteristics. Most disaggregated data for LGBTQ+ people concerned mental illness, sexually transmitted infections, HIV, and substance use.

Currently, English JSNAs do not adequately characterise the needs of local LGBTQ+ communities and disproportionately focus on highly stigmatised behaviours and conditions.

Public health intervention research increasingly adopts a complex systems approach, viewing interventions as events in systems that must adapt to evolving circumstances for sustainability. This study examines how a process of self-evaluation guided by the Action Scales Model (ASM) can enhance adaptive capacity in intervention programmes.

This study reports on the experiences from the Child Life in Healthy Balance (CLHB) programme. Data sources include participant observations, interviews, meeting minutes, and implementation logs from programme developers, project leaders, and local practitioners collected between 2020 and 2024. Observations examined engagement with the ASM during workshops and implementation activities, while interviews illustrated practitioners’ understanding of programme goals and implementation. Meeting minutes documented programme planning and self-evaluation discussions, and implementation logs showed progress and signs of change derived from the programme.

Through practice examples from the CLHB, we demonstrate how the ASM was used as a self-evaluative tool among programme developers and project leaders, as well as a framework for participatory evaluation and communication of programme goals to local practitioners. We highlight signs of capacity building and system change. The ASM facilitated structured discussions on implementation progress and helped align and adjust actions with programme goals. Although practitioners were not always explicitly aware of the ASM, interviews revealed that their understanding of programme goals was aligned with the terminology of the ASM and the overall principles of a systems approach. Some inconsistencies in interpreting the model created uncertainties, yet ASM proved valuable for communicating programme strategies and engaging local practitioners.

The ASM helped align actions with CLHB programme goals, fostering adaptive capacity by reframing and aligning perspectives. These positive experiences suggest that the ASM can be a useful tool for self-evaluation to enhance capacity-building efforts in systems-oriented community health interventions.

Dark kitchens – technology-enabled commercial kitchen(s) operating primarily for delivery, to fulfil remote, on-demand, consumer online orders of food for immediate consumption – are a contemporary addition to the food environment. There are growing concerns around the impact of these food businesses on wider determinants of health, with a paucity of guidelines, regulations and oversight of the dark kitchen sector. This work explored the perceptions of dark kitchens from multiple stakeholder perspectives.

This study recruited key stakeholders (consumers, those working in local authorities and dark kitchens) and applied mixed-methods approaches to explore the definition, identification and regulation of dark kitchens.

Results show confusion and inconsistencies in the way that consumers, local authority departments and other stakeholders define, identify and regulate dark kitchens, resulting in current regulation being difficult to implement. Where local authorities worked cross-departmentally, a more consistent approach to regulating dark kitchens was observed.

The potential risks of dark kitchens to food safety, food hypersensitivities and public health agendas are not fully known and warrant further research and policy development.

The Traveller population is a distinct minority ethnic group, formally recognised by the Irish Government in 2017. Irish Travellers have a lower life expectancy and poorer health expectancy than the general population. Internationally, HPV self-sampling is being considered as an option to improve uptake in cervical screening, particularly in underrepresented groups. It is not currently offered in Ireland, but assessment of acceptability is ongoing. The aim of this study was to determine the uptake of cervical screening and the acceptability of HPV self-sampling in eligible Traveller women.

A face-to-face survey by and with Travellers, adapted from the National Cancer Control Programme’s (NCCP) 2022 National Survey on Cancer Awareness, was conducted by Traveller Community Health workers in partnership with Pavee Point Traveller and Roma Centre.

483 Travellers participated; 306 (63.1%) were women and 191 (39.5%) were in the eligible group for cervical screening (women aged 25-65). Of these, 142 (74%) had ever received an invitation; of those who received an invitation, 125 (89%) attended at least once. Over 73% of those attending cervical screening advised they attended all screening appointments. 37 (19.4%) reported HPV self-sampling as acceptable, 87 (45.5%) as unacceptable to them and 31 (16.2%) were unsure and would like more information. Of the 37 who reported HPV self-sampling as acceptable, 18 (50%) were non (7) or irregular (11) attenders at screening.

HPV self-sampling has the potential to overcome, for some Traveller women, the practical and personal barriers which may prevent them from responding to standard cervical cancer screening.

In the UK, Sudden Unexpected Death in Infancy (SUDI) clusters among priority families (those experiencing multiple and complex problems) where universal infant sleep safety guidance is least effective and alternative multi-agency approaches are required. This project implemented and evaluated multi-agency Eyes on the Baby SUDI prevention in Northumberland, a large rural English county.

A Steering Group comprising diverse organisations oversaw the programme. The multi-agency workforce was grouped by job roles into three training strands based on frequency and type of contact with priority families. Online training was accessed individually or in teams. Normalisation Process Theory (NPT) supported engagement and embedding SUDI prevention into practice. Pre- and post-training surveys assessed staff knowledge and confidence with SUDI prevention. Follow-up surveys captured staff feedback and engagement at 2, 4 and 12 months post-training.

Staff in 187 roles across 25 services were recruited; 607 of the 1007 staff registered completed training. SUDI-prevention knowledge and confidence increased across all strands; knowledge remained high 2 and 4 months after completion. Commitment to SUDI prevention was sustained over time. SUDI-prevention champions helped embed learning into everyday practice. At 1 year, 95% of the 73 staff who responded to follow-up remained actively engaged in SUDI prevention. Staff with limited contact with priority families were the least likely to sustain engagement. At the project conclusion, Northumberland County Council adopted the programme for their pan-Northumberland training platform.

Eyes on the Baby can train and sustain staff engagement in multi-agency SUDI prevention. Key stakeholders with diverse experiences of SUDI prevention oversaw the programme. A Steering Group-led implementation approach encouraged staff to accept SUDI prevention within their roles and was reinforced by team leaders. Early adopters rapidly identified their contribution and engaged enthusiastically as SUDI-prevention champions. One year after training, staff remained engaged, although some roles required additional support.