Whole Systems Approach to Diet and Healthy Weight – Community Pilots Project (PHIRST Connect)

Obesity is a global epidemic affecting all age groups, populations and income levels across continents. The causes of obesity are complex and are routed in health behaviours, environmental factors, government policy and the cultural and built environment. Consequently, a Whole System Approach (WSA) which considers the many causes of obesity and shifts the focus away from individuals as points of intervention and puts an emphasis on understanding and improving the system in which people live in is required.

Whole Systems Approaches (WSAs) have been used to address obesity and healthy weight nationally and internationally. Despite the increased application of WSAs, evidence for effectiveness remains in its infancy (Bagnall et al, 2019). A recent systematic review of 33 studies that included some elements of a WSA showed improved health outcomes: reductions in body mass index (BMI), parental and community awareness, community capacity building, nutrition and physical activity environment changes, and improved safety and wellbeing of community members (Bagnall et al, 2019).

The success of a WSA was attributed to the full engagement of stakeholders and community, good governance, trust and capacity, sufficient time to build real relationships, finance, and the embedding of the WSA within broader policy. Although initial findings are promising, a cautionary approach is advised as many studies that were included in the review do not report what they set out to implement or do not fully evaluate the implementation of a WSA.

Also, methodologies and outcomes reported in some studies were limited, or lacked longitudinal follow-up. Furthermore, consistency in definition, application and evaluation of WSAs is lacking in the available literature. To address some of these shortcomings Public Heath England (2019) provided a six-phase framework and guidance document, referred to as the ‘Leeds Beckett Model’. This operationalises how to apply a local Whole Systems Approach to diet and healthy weight.

The Leeds Beckett Model includes six phases: 1. Set-up; 2. Building the local picture; 3.

Mapping the local picture; 4. Action; 5. Managing the system network; and 6.

Reflect and refresh. To date, the model has been expanded to nine points by Public Health Reform (2019), but a comparison between applying this framework against service as usual or no framework has not been conducted in Scotland or elsewhere. The WSA pilot projects in the East Region offer an opportunity to investigate how WSAs are being implemented and how these change over time.

Aim: To assess the implementation of a Whole Systems Approach to diet and healthy weight and to explore longitudinally the range of levers and opportunities to influence relevant local partnerships and interventions in East Scotland. Research questions:

1. What elements of a WSA model existed within Midlothian and West Lothian prior to the Public Health Scotland pilot project and what did this entail?

2. What is the current practice and how has it changed to either include the Leeds Beckett WSA, continuing usual practice or incorporating an alternative WSA? 3. Which elements of the Leeds Beckett WSA have been implemented locally and what were the reasons for this? 4. How do different Whole Systems Approaches across Midlothian and West Lothian compare?

5. What impact did the implementation of a WSA have on: a) local stakeholders’ knowledge and understanding of how best to address diet and healthy weight issues; and b) local stakeholders’ service planning and delivery ethos, policy and practice? 6. What was the process of implementing the WSA and how was it experienced by local stakeholders?

7. To what extent did the WSA meet the needs of local stakeholders and the community? 8. What were the barriers and enablers to implementing a WSA? 9. To what extent was any implementation of a WSA sustained over time? 10. What factors enabled the sustainability of the WSA? 11. Has adopting a WSA benefitted any other areas of working beyond healthy diet and weight?

12. What are the implications in terms of the resources used, and associated costs, for sustainability of the WSA? What are the: a) most resource intensive activities resulting from the WSA? b) associated costs of these resources, and who bears them?

This programme of research will critically evaluate the evidence for WSAs; assess longitudinally the implementation of a WSA to diet and healthy weight to explore the range of levers (drivers) and opportunities to influence relevant partnerships and interventions to target obesity in East Scotland. The programme consists of four workstreams within a mixed methods framework: 1) Systematic review of reviews of WSAs to diet and healthy weight; 2) Longitudinal qualitative process evaluation of implementing two WSAs in Scotland; 3) Quantitative and Qualitative momentary analysis evaluation of a WSA; and 4) the application of System Dynamics Modelling (SDM) methodology to two council areas in Scotland.

A Public Involvement in Research group (PIRg) have informed each stage of the research process. The research programme’s breadth and its novel nature, mean that it will provide valuable findings for the increasing numbers who commission, deliver, support and evaluate WSAs to diet and healthy weight nationally and internationally.