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      Economic analysis of three interventions of different intensity in improving school implementation of a government healthy canteen policy in Australia: costs, incremental and relative cost effectiveness

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          Abstract

          Background

          No evaluations of the cost or cost effectiveness of interventions to increase school implementation of food availability policies have been reported. Government and non-government agency decisions regarding the extent of investment required to enhance school implementation of such policies are unsupported by such evidence. This study sought to i) Determine cost and cost-effectiveness of three interventions in improving school implementation of an Australian government healthy canteen policy and; ii) Determine the relative cost-effectiveness of the interventions in improving school implementation of such a policy.

          Methods

          An analysis of the cost and cost-effectiveness of three implementation interventions of varying support intensity, relative to usual implementation support conducted during 2013–2015 was undertaken. Secondly, an indirect comparison of the trials was undertaken to determine the most cost-effective of the three strategies. The economic analysis was based on the cost of delivering the interventions by health service delivery staff to increase the proportion of schools ‘adherent’ with the policy.

          Results

          The total costs per school were $166,971, $70,926 and $75,682 for the high, medium and low intensity interventions respectively. Compared to usual support, the cost effectiveness ratios for each of the three interventions were: A$2982 (high intensity), A$2627 (medium intensity) and A$4730 (low intensity) per percent increase in proportion of schools reporting ‘adherence’). Indirect comparison between the ‘high’ and ‘medium intensity’ interventions showed no statistically significant difference in cost-effectiveness.

          Conclusions

          The results indicate that while the cost profiles of the interventions varied substantially, the cost-effectiveness did not. This result is valuable to policy makers seeking cost-effective solutions that can be delivered within budget.

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          Most cited references21

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          Do obese children become obese adults? A review of the literature.

          Obese children may be at increased risk of becoming obese adults. To examine the relationship between obesity in childhood and obesity in adulthood, we reviewed the epidemiologic literature published between 1970 and July 1992. Comparison between studies was complicated by differences in study design, definitions of obesity, and analytic methods used. Although the correlations between anthropometric measures of obesity in childhood and those in adulthood varied considerably among studies, the associations were consistently positive. About a third (26 to 41%) of obese preschool children were obese as adults, and about half (42 to 63%) of obese school-age children were obese as adults. For all studies and across all ages, the risk of adult obesity was at least twice as high for obese children as for nonobese children. The risk of adult obesity was greater for children who were at higher levels of obesity and for children who were obese at older ages. The wide range of estimates in this literature are, in part, due to differences in study designs, definitions of obesity, ages at which participants were measured, intervals between measurements, and population and cultural differences.
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            Impact of policy and built environment changes on obesity-related outcomes: a systematic review of naturally occurring experiments.

            Policies and changes to the built environment are promising targets for obesity prevention efforts and can be evaluated as 'natural'- or 'quasi'-experiments. This systematic review examined the use of natural- or quasi-experiments to evaluate the efficacy of policy and built environment changes on obesity-related outcomes (body mass index, diet or physical activity). PubMed (Medline) was searched for studies published 2005-2013; 1,175 abstracts and 115 papers were reviewed. Of the 37 studies included, 18 studies evaluated impacts on nutrition/diet, 17 on physical activity and 3 on body mass index. Nutrition-related studies found greater effects because of bans/restrictions on unhealthy foods, mandates offering healthier foods, and altering purchase/payment rules on foods purchased using low-income food vouchers compared with other interventions (menu labelling, new supermarkets). Physical activity-related studies generally found stronger impacts when the intervention involved improvements to active transportation infrastructure, longer follow-up time or measured process outcomes (e.g., cycling rather than total physical activity), compared with other studies. Only three studies directly assessed body mass index or weight, and only one (installing light-rail system) observed a significant effect. Studies varied widely in the strength of their design and studies with weaker designs were more likely to report associations in the positive direction.
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              Achieving change in primary care—effectiveness of strategies for improving implementation of complex interventions: systematic review of reviews

              Objective To identify, summarise and synthesise available literature on the effectiveness of implementation strategies for optimising implementation of complex interventions in primary care. Design Systematic review of reviews. Data sources MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from first publication until December 2013; the bibliographies of relevant articles were screened for additional reports. Eligibility criteria for selecting studies Eligible reviews had to (1) examine effectiveness of single or multifaceted implementation strategies, (2) measure health professional practice or process outcomes and (3) include studies from predominantly primary care in developed countries. Two reviewers independently screened titles/abstracts and full-text articles of potentially eligible reviews for inclusion. Data synthesis Extracted data were synthesised using a narrative approach. Results 91 reviews were included. The most commonly evaluated strategies were those targeted at the level of individual professionals, rather than those targeting organisations or context. These strategies (eg, audit and feedback, educational meetings, educational outreach, reminders) on their own demonstrated a small to modest improvement (2–9%) in professional practice or behaviour with considerable variability in the observed effects. The effects of multifaceted strategies targeted at professionals were mixed and not necessarily more effective than single strategies alone. There was relatively little review evidence on implementation strategies at the levels of organisation and wider context. Evidence on cost-effectiveness was limited and data on costs of different strategies were scarce and/or of low quality. Conclusions There is a substantial literature on implementation strategies aimed at changing professional practices or behaviour. It remains unclear which implementation strategies are more likely to be effective than others and under what conditions. Future research should focus on identifying and assessing the effectiveness of strategies targeted at the wider context and organisational levels and examining the costs and cost-effectiveness of implementation strategies. PROSPERO registration number CRD42014009410.
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                Author and article information

                Contributors
                +61 2 4924 6393 , kathryn.reilly@hnehealth.nsw.gov.au
                penny.reeves@hmri.org.au
                simon.deeming@hmri.org.au
                serene.yoong@hnehealth.nsw.gov.au
                luke.wolfenden@hnehealth.nsw.gov.au
                nicole.nathan@hnehealth.nsw.gov.au
                john.wiggers@hnehealth.nsw.gov.au
                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                1471-2458
                20 March 2018
                20 March 2018
                2018
                : 18
                : 378
                Affiliations
                [1 ]ISNI 0000 0000 8831 109X, GRID grid.266842.c, School of Medicine and Public Health, , University of Newcastle, ; Callaghan, NSW 2308 Australia
                [2 ]GRID grid.413648.c, Hunter Medical Research Institute, ; Newcastle, NSW 2300 Australia
                [3 ]ISNI 0000 0000 8831 109X, GRID grid.266842.c, Priority Research Centre for Health Behaviour, , University of Newcastle, ; Callaghan, NSW 2308 Australia
                [4 ]Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287 Australia
                Author information
                http://orcid.org/0000-0002-2862-956X
                Article
                5315
                10.1186/s12889-018-5315-y
                5859495
                0c8a7008-80ca-4023-af0e-1a1953731344
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 6 December 2017
                : 14 March 2018
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Public health
                economic evaluation,implementation strategies,healthy eating policies,childhood obesity

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