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Article ; Online: A systems approach to scale-up for population health improvement

Harriet Koorts / Harry Rutter

Health Research Policy and Systems, Vol 19, Iss 1, Pp 1-

2021 Volume 5

Abstract: Abstract Despite a number of important global public health successes, for many health behaviours there is a continued lack of interventions that have been sufficiently scaled up to achieve system-wide integration. This has limited sustainable and ... ...

Abstract	Abstract Despite a number of important global public health successes, for many health behaviours there is a continued lack of interventions that have been sufficiently scaled up to achieve system-wide integration. This has limited sustainable and equitable population health improvement. Systems change plays a major role in the relation between implementation processes and at-scale institutionalisation of public health interventions. However, in research, systems approaches remain underutilised in scaling up. Public health scale-up models have typically centred on intervention replication through linear expansion. In this paper, we discuss current conceptualisations and approaches used when scaling up in public health, and propose a new perspective on scaling that shifts attention away from the intervention to focus instead on achieving the desired population-level health outcomes. In our view, ‘scaling up’ exists on a continuum. At one end, effective scaling can involve a linear, intervention-orientated expansive approach that prioritises the spread of evidence-based interventions into existing systems in order to drive expansion in the application of that intervention. At the other end, we contend that scale-up can sit within a complex systems paradigm in which interventions are conceptualised as events in systems. In this case, implementation and scale-up activities should focus on generating changes within the system itself to achieve the desired outcome. This we refer to as ‘systems-orientated scale-up’ to achieving population health improvement, which can complement traditional approaches in relevant situations. We argue that for some health behaviours, our proposed approach towards scaling up could enhance intervention implementation, sustainability and population health impact.
Keywords	Systems ; Scale-up ; Public health ; Global health ; Implementation ; Public aspects of medicine ; RA1-1270
Subject code	360 ; 306
Language	English
Publishing date	2021-03-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Complexities and Context of Scaling Up

Harriet Koorts / Jaimie-Lee Maple / Elizabeth Eakin / Mark Lawrence / Jo Salmon

Frontiers in Public Health, Vol

A Qualitative Study of Stakeholder Perspectives of Scaling Physical Activity and Nutrition Interventions in Australia

2022 Volume 10

Abstract: BackgroundScaling up population health interventions is a context-orientated, dynamic and multi-stakeholder process; understanding its influences is essential to enhance future scaling efforts. Using physical activity and nutrition interventions in ... ...

Abstract	BackgroundScaling up population health interventions is a context-orientated, dynamic and multi-stakeholder process; understanding its influences is essential to enhance future scaling efforts. Using physical activity and nutrition interventions in Australia as case examples, the aim of this paper is to identify core influences involved in scaling up physical activity and nutrition interventions, and how these may differ by context and stakeholder.MethodsA qualitative study involving semi-structured telephone interviews with individuals representing academic, government and non-government organizations with involvement in scaling up state and national physical activity and nutrition interventions. Interview questions were derived from the WHO report “20 Questions for Developing a Scaling up Case Study”, and mapped against four key principles and five core areas in the WHO ExpandNet framework for scaling up: (1) The innovation; (2) User organization; (3) Environment; (4) Resource team and; (5) Scale up strategy. Data were analyzed thematically.ResultsNineteen interviews were conducted (government = 3; non-government = 5; and academic = 11 sectors) involving eight scaled up interventions, targeting nutrition (n = 2), physical activity (n = 1) or a combination (n = 5). Most themes aligned to the “Environment”, including: (i) political (e.g., personal agendas); (ii) social (e.g., lack of urgency); and (iii) sector/workforce (e.g., scale up accountability) factors. Themes relating to “Scale up strategy” (e.g., flexibility and evaluation transparency) were next most commonly occurring. Whilst themes were broadly consistent across participants, government participants had a more policy-oriented perspective on the scale up process. Academics discussed a tension between the generation and use of evidence, and the influence of political climates/interest on scale up decisions.ConclusionAttributes of the “Environment” and “Scale up strategy” consistently featured as major influences on successful outcomes, while the role ...
Keywords	scale up ; scaling ; physical activity ; nutrition ; intervention ; stakeholder ; Public aspects of medicine ; RA1-1270
Subject code	360
Language	English
Publishing date	2022-03-01T00:00:00Z
Publisher	Frontiers Media S.A.
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Mechanisms of scaling up

Harriet Koorts / Samuel Cassar / Jo Salmon / Mark Lawrence / Paul Salmon / Henry Dorling

International Journal of Behavioral Nutrition and Physical Activity, Vol 18, Iss 1, Pp 1-

combining a realist perspective and systems analysis to understand successfully scaled interventions

2021 Volume 16

Abstract: Abstract Background Sustainable shifts in population behaviours require system-level implementation and embeddedness of large-scale health interventions. This paper aims to understand how different contexts of scaling up interventions affect mechanisms ... ...

Abstract	Abstract Background Sustainable shifts in population behaviours require system-level implementation and embeddedness of large-scale health interventions. This paper aims to understand how different contexts of scaling up interventions affect mechanisms to produce intended and unintended scale up outcomes. Methods A mixed method study combining a realist perspective and systems analysis (causal loop diagrams) of scaled-up physical activity and/or nutrition interventions implemented at a state/national level in Australia (2010–18). The study involved four distinct phases: Phase 1 expert consultation, database and grey literature searches to identify scaled-up interventions; Phase 2 generating initial Context-Mechanism-Outcome configurations (CMOs) from the WHO ExpandNet framework for scaling up; Phase 3 testing and refining CMOs via online surveys and realist interviews with academics, government and non-government organisations (NGOs) involved in scale up of selected interventions (Phase 1); and Phase 4 generating cross-case mid-range theories represented in systems models of scaling up; validated by member checking. Descriptive statistics were reported for online survey data and realist analysis for interview data. Results Seven interventions were analysed, targeting nutrition (n = 1), physical activity (n = 1), or a combination (n = 5). Twenty-six participants completed surveys; 19 completed interviews. Sixty-three CMO pathways underpinned successful scale up, reflecting 36 scale up contexts, 8 key outcomes; linked via 53 commonly occurring mechanisms. All five WHO framework domains were represented in the systems models. Most CMO pathways included ‘intervention attributes’ and led to outcomes ‘community sustainability/embeddedness’ and ‘stakeholder buy-in/perceived value’. Irrespective of interventions being scaled in similar contexts (e.g., having political favourability); mechanisms still led to both intended and unintended scale up outcomes (e.g., increased or reduced sustainability). Conclusion This paper ...
Keywords	Scale up ; Systems ; Physical activity ; Nutrition ; Intervention ; Realist evaluation ; Nutritional diseases. Deficiency diseases ; RC620-627 ; Public aspects of medicine ; RA1-1270
Subject code	360
Language	English
Publishing date	2021-03-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: A systems thinking approach to understanding youth active recreation

Harriet Koorts / Paul M. Salmon / Christopher T. V. Swain / Samuel Cassar / David Strickland / Jo Salmon

International Journal of Behavioral Nutrition and Physical Activity, Vol 19, Iss 1, Pp 1-

2022 Volume 19

Abstract: Abstract Background Active recreation contributes to child and adolescent physical activity, however, factors affecting uptake are poorly understood at the systems level. The aims of this study were: (1) to use systems analysis methods to understand ... ...

Abstract	Abstract Background Active recreation contributes to child and adolescent physical activity, however, factors affecting uptake are poorly understood at the systems level. The aims of this study were: (1) to use systems analysis methods to understand youth active recreation in Victoria, Australia, (ii) identify potential system leverage points to enhance active recreation, and (iii) explore stakeholder views of systems analysis methods for informing practice and policy decision-making. Methods Phase 1: Umbrella review of systematic reviews (2013–2018), synthesising evidence for correlates, determinants and intervention evidence for promoting active recreation. Phase 2: Development of three systems models (ActorMap and two ActivMaps), depicting active recreation actors/organisations, correlates, determinants and intervention evidence. Phase 3: Development of causal loop diagrams (CLDs) and identification of leverage points based on the Action Scales Model. Phase 4: Model feedback via stakeholder interviews (n = 23; 16 organisations). Results From the literature, 93 correlates and determinants, and 49 intervention strategies were associated with child and adolescent active recreation; the majority located at a social or individual level. Ten potential system leverage points were identified in the CLDs, which differed for pre-schoolers versus children and adolescents. Only time outdoors (an event leverage point) emerged for all age groups. Changes to the built and natural environment (i.e., land use planning, urban design) as a complete domain was a key structural leverage point for influencing active recreation in children and adolescents. Subject matter experts and stakeholder interviews identified 125 actors operating across seven hierarchical active recreation system levels in Victoria. Stakeholder interviews identified 12 areas for future consideration and recommendations for practice/policy influence. Conclusions Our findings underscore the need for dynamic models of system behaviour in active recreation, and ...
Keywords	Physical activity ; Active recreation ; Health behaviour ; Children ; Adolescents ; Systems approach ; Nutritional diseases. Deficiency diseases ; RC620-627 ; Public aspects of medicine ; RA1-1270
Subject code	360
Language	English
Publishing date	2022-05-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: The feasibility and impact of embedding pedagogical strategies targeting physical activity within undergraduate teacher education

Natalie Lander / Harriet Koorts / Emiliano Mazzoli / Kate Moncrieff / Jo Salmon

Pilot and Feasibility Studies, Vol 5, Iss 1, Pp 1-

Transform-Ed!

2019 Volume 16

Abstract: Abstract Purpose Low levels of physical activity and high levels of sedentary behaviour are pervasive, especially in schools. Pre-service teacher education is pivotal to school and educational reform but is an under-studied setting for physical activity ... ...

Abstract	Abstract Purpose Low levels of physical activity and high levels of sedentary behaviour are pervasive, especially in schools. Pre-service teacher education is pivotal to school and educational reform but is an under-studied setting for physical activity and sedentary behaviour intervention research. The objective of this pilot study was to test the feasibility and potential impact of embedding evidence-based active pedagogy based on an adapted version of Transform-Us!, Transform-Ed! in one core unit of an undergraduate teacher education degree. Methods Baseline and follow-up measures (i.e. surveys) were conducted with Bachelor of Education (Primary) pre-service teachers who received the Transform-Ed! intervention and academic educators who delivered the intervention. Focus groups of senior academics and telephone interviews with primary school principals examined perceptions of intervention feasibility and explored potential real-world relevance and impact of pre-service teachers training in active pedagogy. Results After 12 weeks, pre-service teachers (n = 218) were significantly more willing (pre–post change Δ = 0.54, 95% CI [0.16, 0.91]), confident (Δ = 1.40, 95% CI [0.89, 1.91]) and competent (Δ = 2.39, 95% CI [1.85, 2.92]) to deliver Transform-Ed!, had more positive feelings about the impact of physical activity on student outcomes (Δ = 2.05, 95% CI [1.58, 2.52]), and perceived fewer barriers to integrating Transform-Ed! into current and future teaching (Δ = − 7.26, 95% CI [− 8.88, − 5.64]). Four major themes emerged from the focus groups (n = 9) and interviews (n = 5) around participant perceptions of Transform-Ed!: (i) acceptability and appropriateness, (ii) need (tertiary level), (iii) need (primary level) and (iv) overcoming challenges. Conclusion The Transform-Ed! pilot study demonstrated promising results across multiple participant levels, as it was perceived to be feasible, acceptable and appropriate by pre-service teachers, academics and school principals. The findings have direct implications for ...
Keywords	Pre-service teacher education ; Initial teacher education ; Physical activity ; Sedentary behaviour ; Medicine (General) ; R5-920
Subject code	420
Language	English
Publishing date	2019-11-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Exploring when and how adolescents sit

Lauren Arundell / Jo Salmon / Harriet Koorts / Ana Maria Contardo Ayala / Anna Timperio

BMC Public Health, Vol 19, Iss 1, Pp 1-

cross-sectional analysis of activPAL-measured patterns of daily sitting time, bouts and breaks

2019 Volume 9

Abstract: Abstract Background This study describes patterns of adolescents’ objectively-measured sitting volume, sitting bouts, and breaks in sitting during different days and periods of the day, and explored differences by sex and weekdays versus weekend days. ... ...

Abstract	Abstract Background This study describes patterns of adolescents’ objectively-measured sitting volume, sitting bouts, and breaks in sitting during different days and periods of the day, and explored differences by sex and weekdays versus weekend days. Methods ActivPAL™ data were collected in August 2014–December 2015 from adolescents attending secondary government schools in Melbourne Australia. Eight periods (early morning, mid-morning, morning break, late morning, lunch, early afternoon, late-afternoon and evening) were extracted for each day. School time, class time and out-of-school time were also extracted for weekdays. The percentage of time sitting, percentage of each hour in prolonged sitting (sitting bout ≥10 min), and number of sitting breaks/hour were calculated for each period. Differences by sex, and week and weekend days were determined using t-tests. Results Participants (n = 297, 15.4 ± 1.6 years) spent 68% of their day sitting; ~ 30% of each hour in prolonged sitting and 3.1 sitting breaks/hour. Sitting time was greater during class time (75%) and school (70%) compared to out-of-school time (65%). Sitting patterns differed between week and weekend days for all periods except the evening period. Girls had higher proportion of sitting during class than boys (76% vs 72% respectively) and school hours (72% vs 67%), more prolonged sitting during school hours (27% vs 23%), and more sitting breaks per hour during out-of-school time (2.6 vs 2.4), but fewer during class (2.5 vs 3.3) and school hours (2.7 vs 3.3). Sitting patterns did not differ by sex on weekend days. Conclusions Adolescents spent two-thirds of their waking hours sitting, with distinct patterns on weekdays and weekend days. Even though boys and girls were exposed to the same school day routine, girls spent more time sitting and had fewer sitting breaks. Class times, school breaks and the evening period were identified as key intervention periods. Further research is needed to understand the behavioural differences, and guide future ...
Keywords	Sedentary behaviour ; Sitting ; Adolescents ; Sedentary breaks ; Bouts ; prolonged sitting ; School ; Public aspects of medicine ; RA1-1270
Subject code	370
Language	English
Publishing date	2019-06-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Scaling up a school-based intervention to increase physical activity and reduce sedentary behaviour in children

Chris Lonsdale / David R Lubans / Harriet Koorts / Adrian Bauman / Helen Brown / Karen E Lamb / Anna Timperio / Jo Salmon / Taren Sanders / Nicola D Ridgers / Amanda Telford / Lisa Barnett / Lauren Arundell / Samuel K Lai / Jacqueline Della Gatta / Natalie Lander / Katrina Wilhite

BMJ Open, Vol 13, Iss

protocol for the TransformUs hybrid effectiveness–implementation trial

2023 Volume 10

Abstract: Introduction Efficacious programmes require implementation at scale to maximise their public health impact. TransformUs is an efficacious behavioural and environmental intervention for increasing primary (elementary) school children’s (5–12 years) ... ...

Abstract	Introduction Efficacious programmes require implementation at scale to maximise their public health impact. TransformUs is an efficacious behavioural and environmental intervention for increasing primary (elementary) school children’s (5–12 years) physical activity and reducing their sedentary behaviour within school and home settings. This paper describes the study protocol of a 5-year effectiveness–implementation trial to assess the scalability and effectiveness of the TransformUs programme.Methods and analysis A type II hybrid implementation–effectiveness trial, TransformUs is being disseminated to all primary schools in the state of Victoria, Australia (n=1786). Data are being collected using mixed methods at the system (state government, partner organisations), organisation (school) and individual (teacher, parent and child) levels. Evaluation is based on programme Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. RE-AIM domains are being measured using a quasi-experimental, pre/post, non-equivalent group design, at baseline, 12 and 24 months. Effectiveness will be determined in a subsample of 20 intervention schools (in Victoria) and 20 control schools (in New South Wales (NSW), Australia), at baseline, 12 and 24 months. Primary outcomes include TransformUs Reach, Adoption, Implementation and organisational Maintenance (implementation trial), and children’s physical activity and sedentary time assessed using accelerometers (effectiveness trial). Secondary outcomes include average sedentary time and moderate to vigorous-intensity physical activity on weekdays and during school hours, body mass index z-scores and waist circumference (effectiveness trial). Linear mixed-effects models will be fitted to compare outcomes between intervention and control participants accounting for clustering of children within schools, confounding and random effects.Ethics and dissemination The trial was approved by the Deakin University Human Research Ethics Committee (HEAG-H 28_2017), Victorian ...
Keywords	Medicine ; R
Subject code	370
Language	English
Publishing date	2023-10-01T00:00:00Z
Publisher	BMJ Publishing Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Tensions and Paradoxes of Scaling Up

Harriet Koorts / Adrian Bauman / Nancy Edwards / William Bellew / Wendy J. Brown / Mitch J. Duncan / David R. Lubans / Andrew J. Milat / Philip J. Morgan / Nicole Nathan / Andrew Searles / Karen Lee / Ronald C. Plotnikoff

International Journal of Environmental Research and Public Health, Vol 19, Iss 14284, p

A Critical Reflection on Physical Activity Promotion

2022 Volume 14284

Abstract: Background: Achieving system-level, sustainable ‘scale-up’ of interventions is the epitome of successful translation of evidence-based approaches in population health. In physical activity promotion, few evidence-based interventions reach implementation ... ...

Abstract	Background: Achieving system-level, sustainable ‘scale-up’ of interventions is the epitome of successful translation of evidence-based approaches in population health. In physical activity promotion, few evidence-based interventions reach implementation at scale or become embedded within systems for sustainable health impact. This is despite the vast published literature describing efficacy studies of small-scale physical activity interventions. Research into physical activity scale-up (through case-study analysis; evaluations of scale-up processes in implementation trials; and mapping the processes, strategies, and principles for scale-up) has identified barriers and facilitators to intervention expansion. Many interventions are implemented at scale by governments but have not been evaluated or have unpublished evaluation information. Further, few public health interventions have evaluations that reveal the costs and benefits of scaled-up implementation. This lack of economic information introduces an additional element of risk for decision makers when deciding which physical activity interventions should be supported with scarce funding resources. Decision-makers face many other challenges when scaling interventions which do not relate to formal research trials of scale-up; Methods: To explore these issues, a multidisciplinary two-day workshop involving experts in physical activity scale-up was convened by the University of Newcastle, Australia, and the University of Ottawa, Canada (February 2019); Results: In this paper we discuss some of the scale-up tensions (challenges and conflicts) and paradoxes (things that are contrary to expectations) that emerged from this workshop in the context of the current literature and our own experiences in this field. We frame scale-up tensions according to epistemology, methodology, time, and partnerships; and paradoxes as ‘reach without scale’, ‘planned serendipity’ and ‘simple complexity’. We reflect on the implications of these scale-up tensions and paradoxes, providing ...
Keywords	physical activity promotion ; scale-up ; implementation science ; interventions ; research scalability ; scalable interventions ; Medicine ; R
Subject code	306
Language	English
Publishing date	2022-11-01T00:00:00Z
Publisher	MDPI AG
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Identifying facilitators and barriers for adolescents participating in a school-based HIIT intervention

Catherine A. Sharp / Melitta A. McNarry / William T. B. Eddolls / Harriet Koorts / Charles O. N. Winn / Kelly A. Mackintosh

BMC Public Health, Vol 20, Iss 1, Pp 1-

the eXercise for asthma with commando Joe’s® (X4ACJ) programme

2020 Volume 11

Abstract: Abstract Background High-intensity interval training (HIIT) elicits numerous health benefits, but little evidence is available regarding the feasibility of delivering school-based HIIT interventions. The aim of this study was to explore adolescents’ ... ...

Abstract	Abstract Background High-intensity interval training (HIIT) elicits numerous health benefits, but little evidence is available regarding the feasibility of delivering school-based HIIT interventions. The aim of this study was to explore adolescents’ perceptions of a 6-month, 3 × 30-min sessions per week, HIIT intervention delivered either before or after school. Method Eighty adolescents allocated to the intervention group (13.3 ± 1.0 years; 45 boys) were invited to take part in semi-structured focus groups post-intervention. Participants were categorised as attendees (≥40% attendance) or non-attendees (< 5% attendance). Data were transcribed verbatim and thematically analysed deductively, with key emergent themes represented using pen profiles. Results Results showed that a school-based HIIT intervention can be an enjoyable form of exercise. Irrespective of attendance, similar facilitators and barriers to participating were highlighted, including benefits of participation, content of the exercise session and the intervention instructor. Conclusion This study provides support for the delivery of a HIIT intervention in a school setting but highlights the importance of a flexible design and delivery to accommodate competing interests. There is a need to educate adolescents on the possible benefits of participation and to make the sessions enjoyable in order to increase their extrinsic and intrinsic motivation to sustain participation.
Keywords	High-intensity interval training ; School ; Focus groups ; Non-attendee ; Discipline ; Benefits ; Public aspects of medicine ; RA1-1270
Subject code	796
Language	English
Publishing date	2020-05-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: What hinders and helps academics to conduct Dissemination and Implementation (D&I) research in the field of nutrition and physical activity? An international perspective

Harriet Koorts / Patti-Jean Naylor / Rachel Laws / Penelope Love / Jaimie-Lee Maple / Femke van Nassau

International Journal of Behavioral Nutrition and Physical Activity, Vol 17, Iss 1, Pp 1-

2020 Volume 12

Abstract: Abstract Background Ineffective research-practice translation is a major challenge to population health improvement. This paper presents an international perspective on the barriers and facilitators associated with the uptake of and engagement in ... ...

Abstract	Abstract Background Ineffective research-practice translation is a major challenge to population health improvement. This paper presents an international perspective on the barriers and facilitators associated with the uptake of and engagement in Dissemination and Implementation (D&I) research in the fields of physical activity and nutrition. Methods A mixed methods study involving participants from the International Society for Behavioral Nutrition and Physical Activity (ISBNPA) network. Participants completed an online survey (May–July 2018) and/or participated in a focus group during the annual ISBNPA conference (June 2018). Descriptive statistics were generated for quantitative online and pre-focus group survey data. Fisher’s exact tests investigated associations of (i) length of time in academia, (ii) career stage and (iii) country of work, and agreement with ‘perceptions of D&I’. Qualitative data were analysed thematically. Results In total, 141 participants responded to the survey (76% female, 21% aged 35–39 years, 14 countries represented) and 25 participated in focus groups (n = 3). Participants self-identified as having knowledge (48%), skills (53%) and experience supporting others (40%) to conduct D&I research. The majority (96%) perceived D&I was important, with 66% having organizational support for D&I, yet only 52% reported prioritizing D&I research. Perceptions of D&I differed by length of time in academia, career stage and country of work. Barriers included: (i) lack of D&I expertise; (ii) lack of organisational support/value for D&I; (iii) embedded scientific beliefs/culture; (iv) methodological challenges with D&I research; (v) funding/publishing priorities and; (vi) academic performance structures. Facilitators included: (i) increased presence/value of D&I; (ii) collective advocacy; (iii) organisational support for D&I; (iv) recruitment of D&I scientists and; (v) restructure of academic performance models, funding/publishing criteria. ...
Keywords	Implementation ; Dissemination ; Translation ; Physical activity ; Nutrition ; Academia ; Nutritional diseases. Deficiency diseases ; RC620-627 ; Public aspects of medicine ; RA1-1270
Subject code	300
Language	English
Publishing date	2020-01-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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