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The European Policy Evaluation Network (PEN), initiated in autumn 2018, aimed at advancing the evidence base for public policies impacting dietary behaviour, physical activity and sedentary behaviours in Europe. This is needed because non-communicable diseases—the leading cause of global mortality—are substantially caused by physical inactivity and unhealthy dietary behaviours, which in turn are driven by upstream factors that have not yet been addressed effectively by prevention approaches. Thus, successful policy interventions are required that target entire populations and tackle the ‘causes of the causes’. To advance our knowledge on the effective implementation of policies and their impact in terms of improving health behaviours, PEN focused on five research tasks: (i) Adaptation and implementation of a Food Environment Policy Index (Food-EPI) and development of a Physical Activity Environment Policy Index (PA-EPI); (ii) Mapping of health-related indicators needed for policy evaluation and facilitating a harmonized pan-European approach for surveillance to assess the impact of policy interventions; (iii) Refining quantitative methods to evaluate the impact of public policies; (iv) Identifying key barriers and facilitators of implementation of policies; and (v) Advance understanding the equity impact of the development, implementation and evaluation of policies aimed at promoting physical activity and a healthy diet. Finally, and in order to provide concrete evidence for policymaking, existing exemplary policies, namely sugar-sweetened beverages taxation, active transport policies and school policies on nutrition and physical activity were assessed in consideration of these five tasks. At the end of the PEN project’s formal runtime, considerable advancements have been made. Here, we present an overview of the most important learnings and outputs.

Background: Food environments have been recognised as highly influential on population diets. Government policies have great potential to create healthy food environments to promote healthy diets. This study aimed to evaluate food environment policy implementation in European countries and identify priority actions for governments to create healthy food environments. Methods: The Healthy Food Environment Policy Index (Food-EPI) was used to evaluate the level of food environment policy and infrastructure support implementation in Estonia, Finland, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Slovenia, and Spain in 20192021. Evidence of implementation of food environment policies was compiled in each country and validated by government officials. National experts evaluated the implementation of policies and identified priority recommendations. Findings: Finland had the highest proportion (32%, n = 7/22) of policies shaping food environments with a high level of implementation. Slovenia and Poland had the highest proportion of policies rated at very low implementation (42%, n = 10/24 and 36%, n = 9/25 respectively). Policies regarding food provision, promotion, retail, funding, monitoring, and health in all policies were identified as the most important gaps across the European countries. Experts recommended immediate action on setting standards for nutrients of concern in processed foods, improvement of school food environments, fruit and vegetable subsidies, unhealthy food and beverage taxation, and restrictions on unhealthy food marketing to children. Interpretation: Immediate implementation of policies and infrastructure support that prioritize action towards healthy food environments is urgently required to tackle the burden of obesity and diet-related non-communicable diseases in Europe. Funding: This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No 774548 and from the Joint Programming Initiative A Healthy Diet for a Healthy Life. (c) 2022 The Author(s)

Background: Testicular cancer (TC) is the most common malignancy in men under 50 years. Athletes are particularly at risk of testicular trauma and diseases. Experiencing negative testicular symptoms does not necessarily imply that men seek help. Men’s awareness of testicular diseases is often lacking and their intention to seek help for testicular symptoms is sub-optimal. The use of virtual reality (VR) may be effective in promoting men’s awareness of testicular diseases. The Enhancing Men's Awareness of Testicular diseases (E-MAT) feasibility trial aims to test the effect of E-MATVR (intervention; interactive experience using virtual reality [VR]) compared to information delivered Electronically E-MATE (control; same information as E-MATVR delivered as plain text and images) on testicular knowledge, and testicular self-examination among male athletes affiliated with a national sports organisation. The overall aim of this mixed method process evaluation will be to describe (i) the experiences of participants and key stakeholders (e.g., researchers); (ii) the perceived effectiveness of intervention components; (iii) acceptability of the feasibility trial and intervention procedures; (iv) the relationship between implementation, mechanisms, and context; and (v) the barriers and facilitators to support effective conduct of a future definitive trial. Methods: This mixed method process evaluation will use a descriptive realist evaluation. Quantitative data will be gathered using a usability and satisfaction survey, in addition to fidelity checks during intervention delivery. Quantitative data will be analysed using descriptive and inferential statistics. Qualitative data will be gathered from semi-structured interviews and focus groups with participants and key stakeholders to investigate their experiences of E-MATVR and E-MATE, and explore areas for improvement. Thematic analysis of transcripts will be conducted. Conclusions: This process evaluation will provide an in-depth understanding of how the interventions worked within this cohort and lessons for a future definitive trial.

[ISRRF-10] Background: Social prescribing is promoted as a way of targeting socioeconomically deprived populations in need of direct healthcare intervention. Social prescribing interventions link patients in primary care with existing tertiary support services embedded within the community to address the health inequities in mental and physical wellbeing. Non-clinical laypersons often described as “Link Workers” or “Community Health Workers” actively facilitate the connection between patients and relevant community-based support schemes and services in order to complement and stimulate self-management capacity. There are many services available under a social prescribing model but most fall under education, physical activity, signposting, facilitating clinic appointments, and medication adherence. There is no consensus on a universal definition of social prescribing. Given the use of the word social, it does recognize the important role that people and local communities have to play. Randomized and quasi-randomized studies with social prescribing models using laypeople as link workers working with adults with any long-term condition will be included in this study. Studies with professionals (nurses, social workers, allied health practitioners) acting as link workers or studies with participants living in residential care will not be included in the review.

Additional file 3. Full text screening guide. Detailed guidance with exclusion and inclusion criteria used in the full text screening stage.

Additional file 6. AMSTAR 2 assessment. Table showing the quality assessment per AMSTAR item.

Background An upsurge in policy evaluation research within public health sciences has led to multi-disciplinary research networks like the ‘Policy Evaluation Network’ (PEN). This multi-disciplinary collaboration highlighted the need for consensus on clear, common terminology and definitions to facilitate the multi-disciplinary research. This article outlines the development process of the PEN definitions glossary tool, with a focus on the key domains of policy design, implementation and outcomes as they apply to physical activity, sedentary behaviour and dietary behaviours. Methods A project specific participatory process was undertaken, involving PEN researchers (n = 48) from seven European countries across various disciplinary backgrounds. All involved researchers were invited to identify and collate definitions that were commonly used in their research field. Terms and definitions were discussed and debated during three online workshops. Subsequently, the definitions were discussed and refined until consensus was reached. Results Consensus definitions for 93 terms related to the evaluation of policy design, implementation and outcomes are provided. Consensus was reached on a range of terms where the terms were understood and used differently across represented disciplines (e.g. ‘Outcome’ and ‘Impact’). A conceptual ‘Inter-relations in policy-related concepts’ diagram was developed to enable navigation through an online database with key terms. Conclusions The definitions resulting from this participatory process has supported PEN researchers and practitioners across disciplines to reach a shared understanding of different terms related to policy evaluation. Thus, providing a platform for avoiding conflicting use of the same terms in differing contexts over the course of the PEN work programme, facilitating clear and consistent communication, and allowing for clarity within collaborative multi-disciplinary projects and in public-facing messages.

Additional file 2. Medline search strategy. Search string as performed in Medline.

Additional file 4. Example data extraction form. Table showing the different items that were extracted for the umbrella review.

Additional file 9. List of primary studies reported in reviews. A list showing all primary studies that form the evidence base of the included systematic reviews included in the umbrella review, also showing what primary studies have been reported in more than one review.

Additional file 1. PRISMA Checklist. Table explaining where PRISMA items are reported in the manuscript, if applicable.

This report presents the main findings from the 2007 Survey of Lifestyle, Attitudes and Nutrition in Ireland (SL��N 2007). This is the third and largest SL��N survey and the first to include those participating in languages other than English and Irish. Previous studies were carried out in 1998 (Friel et al, 1999) and 2002 (Kelleher et al, 2003). Both these reports are available on the website www.healthpromotion.ie/publications. The main SL��N 2007 survey was conducted through face-to-face interviews. There were two sub-group studies involving (i) measurement of height, weight and waist circumference(sub-group of younger respondents) and (ii) a detailed physical examination (sub-group of older respondents). The overall aim was to provide nationally representative data on the general health, health behaviours and health service use of adults living in Ireland. The two sub-group studies aimed to provide vital information regarding the health risk profiles of younger and older adults. The themes of SL��N 2007 were selected based on current national policy and service priorities. Key documents were consulted, including the National Health Strategy, Quality and Fairness (Department of Health and Children, 2001); the National Health Promotion Strategy (Department of Health and Children, 2000); and the Chief Medical Officer���s 4th Annual Report (Department of Health and Children, 2005). Further consultation across the research consortium, funder and Advisory Group produced a prioritised and manageable set of items to assess. A key requirement was to provide a core set of national population health data that would enable comparison within study sub-groups (gender, age and social class), across health service regions within the Health Service Executive (HSE), with other key comparison populations (particularly Northern Ireland) and with previous SL��N surveys. The SL��N 2007 survey was funded by the Health Promotion Policy Unit of the Department of Health and Children. The survey and analyses were carried out by the SL��N 2007 Consortium, consisting of the Royal College of Surgeons in Ireland (RCSI), the National University of Ireland, Cork (UCC), the National University of Ireland, Galway (NUIG) and the Economic and Social Research Institute (ESRI).

Additional file 5. Revised AMSTAR 2. Table showing all AMSTAR items and how certain items were revised before quality appraisal.

Government policies that promote healthy food environments are considered promising to reduce socioeconomic inequalities in diet. Empirical evidence of effects on these inequalities, however, is relatively scarce and, with a few exceptions, tends to be inconclusive. We use two contemporary theories that help to understand socioeconomic inequalities in health and health-related behaviours (Bourdieu’s capital theory and Mullainathan and Shafir’s scarcity theory) to reason how policies influencing food environments may differentially impact lower and higher socioeconomic groups. In essence, these theories enable us to understand how specific elements of broader daily living conditions (e.g. social practices that lead to habitus formation, material conditions that shape experiences of scarcity) may lead to a greater benefit of certain food environment policies for the healthfulness of diets of lower or higher socioeconomic groups. We conclude that the application of theories on the mechanisms underlying socioeconomic inequalities in health can help to guide future empirical studies in testing theory-based hypotheses on differential effects of policies, and thereby enhance the development of effective policies tackling socioeconomic inequalities in dietary intakes.

Additional file 7. List of excluded articles. A list of the articles that were excluded at full text screening, with five different exclusion reasons.

Additional file 8. Study characteristics. Table describing study characteristics and key findings of included systematic reviews.

Background Food environments impact on diets, obesity and non-communicable diseases (NCDs). Government policies are essential to create healthy food environments. This study aimed to assess the strength of European Union (EU)-level policies, and identify and prioritize actions for the EU to create healthy food environments. Methods The Healthy Food Environment Policy Index (Food-EPI) was applied. The Food-EPI included 26 policy and 24 infrastructure support indicators. Independent experts (n = 31) rated the strength of EU-level policies and infrastructure support for each of these indicators (on a 5-point scale, from very weak to very strong) and identified and prioritized actions to improve food environments. Results For 65% of the 26 policy indicators, EU-level policies were rated as weak and for 23% as very weak. For 63% of the 24 infrastructure support indicators, EU-level policies were rated as moderate and for 33% as weak. The experts recommended 18 policy and 19 infrastructure support actions to the EU. The Top 5 prioritized policy actions included three actions in the food composition domain (e.g. setting mandatory food composition targets), one action in the food prices domain and one action in the food promotion domain. The Top 5 prioritized infrastructure support actions included three actions in the leadership domain (e.g. developing a high-level NCDs Prevention Strategy) and two actions in the monitoring domain. Conclusions There is large potential for the EU to strengthen its policies and infrastructure support in order to improve food environments. This study specifies priority actions for the EU to create healthy food environments.

Socioeconomic inequalities in diets need to be tackled to improve population diets and prevent obesity and diet-related non-communicable diseases. The potential of food environment policies to reduce such inequalities has to date however not been appraised. The objective of this umbrella review was to assess the impact of food environment policies on socioeconomic inequalities in diets and to identify knowledge gaps in the existing literature, using the Healthy Food Environment Policy Index as a conceptual framework. The policies considered in the umbrella review are within six domains: 1) food composition 2) food labelling 3) food promotion 4) food provision 5) food retail 6) food pricing. A systematic search for systematic literature reviews on the effect of food environment policies on dietary-related outcomes across socioeconomic groups and published in English between 2004 and 2019 was conducted. Sixteen systematic literature reviews encompassing 159 primary studies were included, covering food composition (n = 2), food labelling (n = 3), food provision (n = 2), food prices (n = 13) and food in retail (n = 4). Quality assessment using the “Assessing the Methodological Quality of Systematic Reviews” quality rating scale showed that review quality was mainly low or critically low. Results suggest that food taxation may reduce socioeconomic inequalities in diets. For all other policy areas, the evidence base was poor. Current research largely fails to provide good quality evidence on impacts of food environment policies on socioeconomic inequalities in diets. Research to fill this knowledge gap is urgently needed. The PEN project (www.jpi-pen.eu) is funded by the Joint Programming Initiative “A Healthy Diet for a Healthy Life” (JPI HDHL), a research and innovation initiative of EU member states and associated countries. The funding agencies supporting this work are (in alphabetical order of participating countries): Ireland: Health Research Board (HRB); The Netherlands: The Netherlands Organisation for Health Research and Development (ZonMw); New Zealand: The University of Auckland, School of Population Health; Norway: The Research Council of Norway (RCN).

All physical activity (PA) behaviours undertaken over the day, including sleep, sedentary time, standing time, light-intensity PA (LIPA) and moderate-to-vigorous PA (MVPA) have the potential to influence cardiometabolic health. Since these behaviours are mutually exclusive, standard statistical approaches are unable to account for the impact on time spent in other behaviours. Objective By employing a compositional data analysis (CoDA) approach, this study examined the associations of objectively measured time spent in sleep, sedentary time, standing time, LIPA and MVPA over a 24-h day on markers of cardiometabolic health in older adults. Methods Participants (n =366; 64.6 years [5.3]; 46% female) from the Mitchelstown Cohort Rescreen Study provided meas- ures of body composition, blood lipid and markers of glucose control. An activPAL3 Micro was used to obtain objective measures of sleep, sedentary time, standing time, LIPA and MVPA, using a 7-day continuous wear protocol. Regression analysis, using geometric means derived from CoDA (based on isometric log-ratio transformed data), was used to examine the relationship between the aforementioned behaviours and markers of cardiometabolic health. Results Standing time and LIPA showed diverging associations with markers of body composition. Body mass index (BMI), body mass and fat mass were negatively associated with LIPA (all p

This report presents the main findings from the 2007 Survey of Lifestyle, Attitudes and Nutrition in Ireland (SLÁN 2007). This is the third and largest SLÁN survey and the first to include those participating in languages other than English and Irish. Previous studies were carried out in 1998 (Friel et al, 1999) and 2002 (Kelleher et al, 2003). Both these reports are available on the website www.healthpromotion.ie/publications. The main SLÁN 2007 survey was conducted through face-to-face interviews. There were two sub-group studies involving (i) measurement of height, weight and waist circumference(sub-group of younger respondents) and (ii) a detailed physical examination (sub-group of older respondents). The overall aim was to provide nationally representative data on the general health, health behaviours and health service use of adults living in Ireland. The two sub-group studies aimed to provide vital information regarding the health risk profiles of younger and older adults. The themes of SLÁN 2007 were selected based on current national policy and service priorities. Key documents were consulted, including the National Health Strategy, Quality and Fairness (Department of Health and Children, 2001); the National Health Promotion Strategy (Department of Health and Children, 2000); and the Chief Medical Officer’s 4th Annual Report (Department of Health and Children, 2005). Further consultation across the research consortium, funder and Advisory Group produced a prioritised and manageable set of items to assess. A key requirement was to provide a core set of national population health data that would enable comparison within study sub-groups (gender, age and social class), across health service regions within the Health Service Executive (HSE), with other key comparison populations (particularly Northern Ireland) and with previous SLÁN surveys. The SLÁN 2007 survey was funded by the Health Promotion Policy Unit of the Department of Health and Children. The survey and analyses were carried out by the SLÁN 2007 Consortium, consisting of the Royal College of Surgeons in Ireland (RCSI), the National University of Ireland, Cork (UCC), the National University of Ireland, Galway (NUIG) and the Economic and Social Research Institute (ESRI).

Is ��ard at�� sa tuarasc��il seo na pr��omhthortha�� �� Shuirbh�� ar N��sanna Maireacht��la, Dearca�� agus Coth�� in ��irinn 2007 (SL��N 2007). Is �� seo an tr���� suirbh�� SL��N agus an suirbh�� is m�� agus is �� seo an ch��ad suirbh�� a ��ir��tear teangacha eile ann seachas B��arla agus Gaeilge. Rinneadh staid��ir eile roimhe seo in 1998 (Friel et al, 1999) agus 2002 (Kelleher et al, 2003). T�� an d�� thuarasc��il seo le f��il ar an l��ithre��n gr��as��in www.healthpromotion.ie/publications. Rinneadh pr��omhshuirbh�� SL��N 2007 tr�� agallaimh duine le duine. Bh�� dh�� staid��ar foghr��pa ann (i) tomhas airde, me��chain agus iml��ne coime (foghr��pa freagr��ir�� n��os ��ige) agus (ii) scr��d�� fisici��il n��os mionsonraithe (foghr��pa de fhreagr��ir�� n��os sine). Is �� a bh�� mar aidhm leis an staid��ar sonra�� n��isi��nta maidir le sl��inte ghinear��lta, iompra��ochta�� sl��inte agus ��s��id seirbh��s�� sl��inte a bhaili�� i measc daoine f��sta a bhfuil c��na�� orthu in ��irinn. Dh��righ staid��ar an d�� fhoghr��pa ar eolas r��th��bhachtach maidir le pr��if��l�� riosca sl��inte daoine f��sta n��os ��ige agus n��os sine a shol��thar. Roghna��odh t��ama�� SL��N 2007 bunaithe ar thosa��ochta�� reatha n��isi��nta beartais agus seirbh��se. Baineadh ��s��id as pr��omhch��ip��is�� lena n-��ir��tear an Strait��is N��isi��nta Sl��inte, Ardchaighde��n agus Cothroime (An Roinn Sl��inte agus Leana��, 2001); an Strait��is N��isi��nta um Chur chun Cinn na Sl��inte (An Roinn Sl��inte agus Leana��, 2000); agus ceathr�� Tuarasc��il Bhliant��il an Phr��omh-Oifigigh Mh��ochaine (An Roinn Sl��inte agus Leana��, 2005). Tr�� chomhairli��ch��n breise leis an gcuibhreannas taighde, chuir an Gr��pa Maoini��ch��in agus Comhairleach sraith m��reanna tosa��ochta agus sol��imhsithe a bh�� le meas le ch��ile. Pr��omhriachtanas ba ea sraith pr��omhshonra�� sl��inte den daonra n��isi��nta a shol��thar ��� sonra�� a chiall��dh go mbeadh s�� ind��anta compar��id a dh��anamh laistigh d���fhoghr��pa�� staid��ir (inscne, aois agus aicme sh��isialta), sna r��igi��in seirbh��se sl��inte laistigh d���Fheidhmeannacht na Seirbh��se Sl��inte (HSE), agus le pr��omhdhaonra�� compar��ide eile (go h��irithe Tuaisceart ��ireann) mar aon le suirbh��anna SL��N a rinneadh roimhe seo. Ba �� an tAonad Coth�� Sl��inte agus Beartais sa Roinn Sl��inte agus Leana�� a mhaoinigh SL��N 2007. Ba �� cuibhreannas SL��N 2007 a rinne na suirbh��anna agus an anail��s. I measc chomhalta�� an Chuibhreannais bh�� Col��iste R��oga na M��inle�� in ��irinn (RCSI), Col��iste na hOllscoile, Corcaigh (UCC), Ollscoil na h��ireann, Gaillimh (O��G) agus an Institi��id Taighde Eacnama��ochta agus S��isialta (ESRI).

Table S1. Odds ratios (OR) and 95% confidence intervals (CI) derived from binominal logistic regression analyses as indicators of association between physical activity (PA) and covariates and depressive symptoms. (DOCX 17 kb)

SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents*. (DOC 122 kb)

The success of childhood weight management programmes relies on family engagement. While attendance offers many benefits including the support to make positive lifestyle changes, the majority of families referred to treatment decline. Moreover, for those who do attend, benefits are often compromised by high programme attrition. This systematic review investigated factors influencing attendance at community-based lifestyle programmes among families of over-weight or obese children. A narrative synthesis approach was used to allow for the inclusion of quantitative, qualitative and mixed-method study designs. Thirteen studies met the inclusion criteria. Results suggest that parents provided the impetus for programme initiation, and this was driven largely by a concern for their child's psychological health and wellbeing. More often than not, children went along without any real reason or interest in attending. Over the course of the programme, however, children's positive social experiences such as having fun and making friends fostered the desire to continue. The stigma surrounding excess weight and the denial of the issue amongst some parents presented barriers to enrolment and warrant further study. This study provides practical recommendations to guide future policy makers, programme delivery teams and researchers in developing strategies to boost recruitment and minimise attrition.

BackgroundChildhood obesity is complex, and its aetiology is known to be multifaceted. The contribution of lifestyle behaviors, including poor diet and physical inactivity, to obesity remains unclear. Due to the current high prevalence, childhood obesity is an urgent public health priority requiring current and reliable data to further understand its aetiology. ObjectiveThe objective of this study is to explore the individual, family, and environmental factors associated with childhood overweight and obesity, with a specific focus on diet and physical activity. A secondary objective of the study is to determine the average salt intake and distribution of blood pressure in Irish children. MethodsA cross-sectional survey was conducted of children 8-11 years old in primary schools in Cork, Ireland. Urban schools were selected using a probability proportionate to size sampling strategy, and a complete sample of rural schools from one area in Cork County were invited to participate. Information collected included physical measurement data (anthropometric measurements, blood pressure), early morning spot and 24 hour urine samples, a 3 day estimated food diary, and 7 days of accelerometer data. Principal- (school head) reported, parent/guardian-reported, and child-reported questionnaires collected information on lifestyle behaviors and environmental attributes. The Cork Children’s Lifestyle Study (CCLaS) was designed by the Department of Epidemiology and Public Health in University College Cork, Ireland in 2011 and 2012. Piloting and modification of study methods was undertaken. Data collection took place between April 2012 and June 2013. ResultsOverall, 27/46 schools and 1075/1641 children, of which 623 were boys, participated. Preliminary data analysis is underway. It is anticipated that the results of the CCLaS study will be available in late 2014. ConclusionsThe CCLaS study has collected in-depth data on a wide range of individual, family, social, and environmental correlates which will allow us to access multilevel influences on childhood obesity. This study will contribute to the evidence base by highlighting current knowledge and gaps regarding the predominant drivers of childhood obesity.

This report presents the main findings on self-reported medically attended injuries in Irish adults from the 2007 Survey of Lifestyle, Attitudes and Nutrition (SLÁN 2007) in Ireland, commissioned by the Department of Health and Children. The report is part of a series presenting in-depth findings from the SLÁN 2007 Main Report (Morgan et al, 2008). The SLÁN 2007 survey involved face-to-face interviews in the homes of 10,364 randomly selected adults, aged 18 years and over, with sub-studies on body size and a detailed physical examination. There was a 62% response rate to the survey. The sample is representative of the general population in Ireland when compared with Census 2006 figures and was further weighted, for the purpose of analysis, to match population characteristics. SLÁN 2007 is the largest national health survey among the Irish adult population to date and also the largest to study the extent of injuries among the adult population. As part of the main survey, respondents were asked a series of questions on injuries requiring medical attendance (i.e. injuries resulting in medical treatment), on the circumstances surrounding the occurrence of injury events, the mechanism that caused the injury and the severity of the injury. This report presents the findings from SLÁN 2007 on injuries in Ireland and considers the influence of such key socio-demographic variables as age, gender, social class, education, income, residential location, employment status and marital status.

The main SLÁN 2007 survey was conducted through face-to-face interviews. There were two sub-group studies involving (i) measurement of height, weight and waist circumference (subgroup of younger respondents) and (ii) a detailed physical examination (sub-group of older respondents). The overall aim was to provide nationally representative data on the general health, health behaviours and health service use of adults living in Ireland. The two sub-group studies aimed to provide vital information regarding the health risk profiles of younger and older adults, and at the same time offer the first opportunity to compare measured and self-reported anthropometric data from the general Irish population. This report presents the detailed diet and nutrition findings from SLÁN 2007, analysed in accordance with current Irish dietary guidelines. Identification of dietary behaviours and dietary patterns in the Irish population at national level is essential to enhance our understanding of the relationships between diet and disease, and to monitor changes over time. As with previous SLÁN surveys, these patterns were assessed using a comprehensive Food Frequency Questionnaire adapted for use in the Irish population. Due to the changing nature of Irish society, additional information relating to meal patterns, snacking and food consumption outside the home were also included in the main survey. The SLÁN 2007 survey was funded by the Health Promotion Policy Unit of the Department of Health and Children. The survey and analyses were carried out by the SLÁN 2007 Consortium, consisting of the Royal College of Surgeons in Ireland (RCSI), University College, Cork (UCC), the National University of Ireland, Galway (NUIG) and the Economic and Social Research Institute (ESRI).

One of the main characteristics of poverty in rural ireland is its seemingly invisible nature. Rural areas, unlike some urban areas, do not present homogenous areas of advantage and disadvantage, they are diverse and the experience of poverty is often individual and dispersed over a greater geographical area. In many rural areas, disadvantage and marginalization remain significant problems. peer-reviewed

Background and aim: Childhood obesity is a significant public health issue. International guidelines continue to recommend family-focused, multicomponent, childhood weight management programmes despite limited evidence on their effectiveness or implementation in real-world settings. In 2014, the Irish Health Service proposed a national pilot of the W82GO-community programme. The overall aim of this thesis was to investigate the barriers and facilitators to the implementation of W82GO-community and explore the factors influencing family engagement. Methods: W82GO-community aimed to improve nutrition, increase physical activity and facilitate behaviour change in children aged 5-7 years who measured ≥98th percentile over one year. It was piloted in two community sites by two multidisciplinary teams from April 2015 to April 2016. Firstly, a qualitative study was conducted to explore implementation from the perspective of 29 national and local level stakeholders responsible for implementing the programme including professionals from dietetics, psychology, public health nursing, physiotherapy, health promotion and administration. Framework analysis was used to identify barriers and facilitators which were mapped onto a well-known implementation framework. Secondly, a systematic review of international literature was carried out to investigate what factors influence attendance at similar community-based lifestyle programmes among families of overweight or obese children. This was followed by another qualitative study exploring public health nurses (PHNs) experiences of referring families to, and families’ feelings of being referred to, W82GO-community. It also investigated families’ motivation to participate in and complete treatment. Finally, in light of findings from the aforementioned studies a cross-sectional analysis of data collected as part of the Cork Children’s Lifestyle Survey (CCLaS) was conducted to identify factors influencing parent and child misperception of child weight. Results: For all stakeholders, barriers to the implementation of W82GO-community arose due to the multidisciplinary nature of the programme, including the lack of role clarity and added complexity of working in different locations. Furthermore, a lack of parental engagement, as evidenced by low enrolment and retention rates, presented a further challenge for programme implementation. Of the 121 children who were eligible for initial assessment, less than half of families accepted the invitation and of those who presented, 19 subsequently started the programme. Just eight families completed the W82GO-community programme. The systematic review on barriers and facilitators to family attendance and retention found that parents are largely driven to enrol because of a concern for their child’s psychological health and wellbeing. However, the stigma surrounding excess weight and the denial of the issue amongst some parents presents significant barriers to enrolment. The systematic review findings also suggest that over the course of a programme, children’s positive social experiences such as having fun and making friends foster the desire to continue participating in treatment. Results from our qualitative study involving PHNs and parents who participated in W82GO-community found that both PHNs and parents were fearful of the referral process. They had concerns about both the practicality of making the referral and the significance of the referral on the health and wellbeing of the child, respectively. Despite these initial fears, parents concern for their child’s future was a major driver behind their participation. Finally, the cross-sectional analysis of CCLaS data highlighted that 45% of parents of overweight/obese children underestimated their child’s weight and this was influenced by child age and child misperception of own weight. 77% of overweight/obese children misclassified their own weight. Conclusion: This thesis provides critical evidence on the complexities associated with implementing a multidisciplinary childhood weight management programme in real-world settings. It provides practical recommendations to guide future policy makers, programme delivery teams and researchers, in particular, when developing strategies to boost recruitment, minimise attrition and subsequently enhance effectiveness. Findings highlight the profound limitations of family-focused, community-based, weight management programmes and confirm the critical need for broader societal intervention.