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The article analyzes papers published in the journal with the term "complexity" in title and abstracts in an effort to provide a description and reflection on complexity diffusion in the health promotion community. Topics covered include the finding that complexity often was referred to as a generic descriptive term without any association to complexity concepts, theories or frameworks, and a summary of revised papers and their contribution to complexity informed health promotion practice.

Intersectoral collaborations are recommended as effective strategies to reduce health inequalities. People most affected by health inequalities, as are people living in poverty, remain generally absent from such intersectoral collaborations. Community-based participatory research (CBPR) projects can be leveraged to better understand how to involve people with lived experience to support both individual and community empowerment. In this paper, we offer a critical reflection on a CBPR project conducted in public housing in Québec, Canada, that aimed to develop intersectoral collaboration between tenants and senior executives from four sectors (housing, health, city and community organizations). This single qualitative case study design consisted of fieldwork documents, observations and semi-structured interviews. Using the Emancipatory Power Framework (EPF) and the Limiting Power Framework (LPF), we describe examples of types of power and resistance shown by the tenants, the intersectoral partners and the research team. The discussion presents lessons learned through the study, including the importance for research teams to reflect on their own power, especially when aiming to reduce health inequalities. The paper concludes by describing the limitations of the analyses conducted through the EPF–LPF frameworks and suggestions to increase the transformative power of future studies. [ABSTRACT FROM AUTHOR]

Using the concept of methodological congruence—where the different elements of a study 'fit' together—we explore both problematic and good practice in (reflexive) thematic analysis (TA) as reported in Health Promotion International (HPI). Aligning with the importance we place on 'owning your perspectives' we situate this exploration in relation to our understanding of the variation in approaches to TA and qualitative research more broadly. This contextualization is necessary for highlighting why we judge practices to be in/congruent, and to facilitate more knowing congruence in future research. We critically reviewed a 'sample' of 31 papers published in HPI between 2010 and 2023 citing Braun and Clarke as reference for TA. We overview a range of problematic and good features of the use of TA in HPI , before focusing on two domains that seemed to present key challenges: theory and themes. Methodological incongruence can occur when postpositivist values and practices unwittingly creep into ostensibly non-positivist TA; we encourage thoughtfully and what we term 'knowing' consideration of theory, and quality practices and criteria. Methodological incongruence can also occur through mismatched conceptualizations of themes—notably, the use of 'topic summaries' as themes for reflexive TA (and fragmented thematic structures with 'thin' themes). We provide examples from the reviewed papers to demonstrate good practice in researcher reflexivity, articulation of theoretical and methodological frameworks and congruent themes. However, mindful of power dynamics, we only discuss problematic practice in general terms, to protect author anonymity. To facilitate thoughtful, quality TA—of all kinds—we provide eight pointers for researchers (and reviewers) to guide quality practice, and facilitate the use of concepts, procedures and criteria that promote knowing methodological congruence. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various topics within the issue, including health promoting schools, health literacy, educational leadership, and the efficacy of HPS in fruit and water consumption.

For years Gross Domestic Product (GDP) has served as a key indicator of human progress and "successful" societies. Unfortunately, GDP has failed to robustly capture the human experience or predict resilience through crises; and obscures the presence of inequity -- a key determinant of suffering. It is clear the global community needs a new organizing principle: one that envisions and measures progress by focusing on the conditions that support health, resilience, and overall wellbeing. This paper examines key health promotion concepts and approaches, juxtaposed with philosophical underpinnings of the concept of wellbeing, alternative measurement strategies, and examples of wellbeing policy initiatives. In doing so, the paper highlights the relevance of wellbeing policy frameworks to health promotion, the utility of health promotion strategies for implementing wellbeing policy frameworks, and controversies and pitfalls that require consideration. The paper concludes by outlining how health promotion is uniquely poised to contribute to wellbeing policy frameworks that promote the sources of human and planetary thriving through sustainable development, and that promoting a wellbeing agenda can strengthen efforts to promote health by addressing social determinants and ensuring universal access to resources that support coping with emerging challenges and strengthen resilience. [ABSTRACT FROM AUTHOR]

Since launching health health-promoting settings approach to health by WHO, valuable progress has happened in implementing its holistic concepts in settings such as cities, schools, workplaces, hospitals and healthcare services. However, significant knowledge–intention–success gaps still exist in creating sustainable health-promoting changes in settings. The complexity of the task of bridging this gap has contributed to the call for a complexity-informed paradigm shift to health as well as settings, followed by increasing consultation of relevant complexity theories, frameworks and tools in health research. This paper provides a critical scoping review of the application of complex adaptive system (CAS) theory in settings-based health promotion research. We included 14 papers, mostly qualitative studies, reporting on planning or implementation of change initiatives, less on its evaluation. CAS theory application was often incomplete thereby reducing the potential benefit of using this lens to understand change management. We suggest some recommendations how to comprehensively apply the CAS theory in setting-based health research and to report on all CAS characteristics to enhance the understanding of settings as adaptive health-promoting settings. [ABSTRACT FROM AUTHOR]

Gender equality indexes (GEIs) have become a popular tool for the quantification of unequal resource distribution between males and females. Creating such an index implies an understanding of what gender inequality is, though this question has remained the province of theoretical feminism with little explicit treatment in the methodologically focussed literature. This paper presents an empirically minded, theoretical account of gender inequality, which can be used broadly to inform the development of GEIs. The account proceeds in three steps. First, we argue for a broad understanding of the types of resources that structure gender inequality. Drawing on the work of Bourdieu, we highlight the importance of including symbolic capitals (and indeed viewing gender itself as a symbolic capital). By considering gender as a symbolic capital, we are drawn to the ways that normative maleness hides some types of gender inequality. Thus, caregiving norms and leisure time inequality are brought to the foreground. Finally, in recognizing that there is no single unifying female experience, we describe the ways that gender inequality intersect with other forms of disadvantage, motivating the incorporation of (particularly) race into the index. The result is a comprehensive—and theoretically defensible—set of indicators for the measurement of gender inequality. [ABSTRACT FROM AUTHOR]

Community participation is a central concept for health promotion, covering a breadth of approaches, purposes and activities. This paper reports on a national knowledge translation project in England, UK, which resulted in a conceptual framework and typology of community-based approaches, published as national guidance. A key objective was to develop a conceptual framework linked to sources of evidence that could be used to support increased uptake of participatory methods across the health system. It was recognized that legitimacy of community participation was being undermined by a scattered evidence base, absence of a common terminology and low visibility of community practice. A scoping review, combined with stakeholder consultation, was undertaken and 168 review and conceptual publications were identified and a map produced. A 'family of community-centred approaches for health and wellbeing' was then produced as way of organizing the evidence and visually representing the range of intervention types. There are four main groups, with sub-categories: (i) strengthening communities, (ii) volunteer and peer roles, (iii) collaborations and partnerships and (iv) access to community resources. Each group is differentiated using key concepts and theoretical justifications around increasing equity, control and social connectedness. An open access bibliography is available to accompany the framework. The paper discusses the application of the family of community-centred approaches as a flexible planning tool for health promotion practice and its potential to be used as a framework for organizing and synthesizing evidence from a range of participatory methods. [ABSTRACT FROM AUTHOR]

Health impact assessment (HIA) is a method by which a policy, programme or project falling outside traditional health fields, may be judged as to its potential effects on the health of a population to mitigate negative impacts and strengthen the positive ones. Proposals are analysed from the perspective of all the determinants of health. In France, HIAs are mainly applied to urban development projects where social cohesion (SCo) is a major issue. Although the HIA method is well structured as a step-by-step process, there are no guidelines for assessing SCo. This article opens with literature review to clarify the concept of SCo and to understand how the built environment influences SCo and how social environment influence health. Drawing on this work, this paper presents an analytical framework to assess SCo, integrating both the spatial and physical dimensions of urban design and the perceptions of the neighbourhood characteristics. Following a brief overview of the key findings from applying this framework to HIA of an urban development project, the paper discusses its related strengths and weaknesses. The framework could be a useful tool for HIA as it embraces knowledge from both urban planning and social sciences. It also allows for an overall analysis of all the indicators without relying on a checklist. Nevertheless, it should be tested further to improve its validity. [ABSTRACT FROM AUTHOR]

From the year 2003 when the first walkability scale was published to date, person-environment fit models and empirical research, some of which was published in Health Promotion International , have encapsulated healthy communities in 'neighborhood walkability'. While there is no doubt that neighborhood walkability positively influences health-seeking behaviors and health, recent models suggest that their measurement and conceptualization have not emphasized the role played by psychosocial and personal factors in aging in place. Thus, the development of scales measuring human ecosystem factors has not recognized all critical factors suited for older adults. In this paper, we aim to draw on relevant literature to frame a more holistic construct, hereby referred to as Socially Active Neighborhoods (SAN), that would better support aging in place in older populations. Through a narrative review based on a systematic search of the literature, we define the scope of SAN and delineate some contextual implications for gerontology, health promotion and psychometric testing. SAN, unlike neighborhood walkability in its current measurement and conceptualization, incorporates critical theory-informed psychosocial factors (i.e. safety and disability friendliness of neighborhood infrastructure) that can encourage older adults with physiological and cognitive limitations to maintain physical and social activities as well as health in later life. The SAN is the result of our adaptation of key person-environment models, including the Context Dynamics in Aging (CODA) framework, that recognizes the role of context in healthy aging. [ABSTRACT FROM AUTHOR]

Failure of governments across the world to address climate change has fuelled social movements focused on climate-related policy and action. Research analysing these movements has focused mainly on the types of strategies employed including blockades and occupations, marches and petitions, divestment, boycotts and litigation as well as how groups are framing climate change as a problem. What has been largely missed are the ways these groups are framing the change they want to see, that is their demands to governments. Not all demands and actions have the same potential to create the changes needed to mitigate climate change. Used in public health and health promotion, the systems science Intervention Level Framework (ILF) is a tool that can help analyse to what extent different demands have the leverage to create change in a system. We use the ILF to analyse 131 demands from 35 different climate-related advocacy groups in Australia. Results show demands are more focused on lower system leverage points, such as stopping particular projects, rather than on more impactful leverage points, such as the governance structures that determine climate-related policy and decision-making mechanisms. Further, the results highlight the lack of attention on public health related topics of transport and food systems. This paper shows how a systems science framework used in health promotion, the ILF, could enable climate advocacy groups to more effectively target demands to achieve more impactful outcomes from governments, corporations and the public. [ABSTRACT FROM AUTHOR]

Reducing disease prevalence rather than promoting health has long been the objective of significant population health initiatives, such as the social determinants of health (SDH) framework. However, empirical evidence suggests that people with diagnosed diseases often answer the self-reported health (SRH) question positively. In pursuit of a better proxy to understand, measure and improve health, this scoping review of reviews examines the potential of SRH to be used as an outcome of interest in population health policies. Following PRISMA-ScR guidelines, it synthesizes findings from 77 review papers (published until 11 May 2022) and reports a robust association between SDH and SRH. It also investigates inconsistencies within and between reviews to reveal how variation in population health can be explained by studying the impact of contextual factors, such as cultural, social, economic and political elements, on structural determinants such as socioeconomic situation, gender and ethnicity. These insights provide informed hypotheses for deeper explorations of the role of SDH in improving SRH. The review detects several gaps in the literature. Notably, more evidence syntheses are required, in general, on the pathway from contextual elements to population SRH and, in particular, on the social determinants of adolescents' SRH. This study reports a disease-oriented mindset in collecting, analysing and reporting SRH across the included reviews. Future studies should utilize the capability of SRH in interconnecting social, psychological and biological dimensions of health to actualize its full potential as a central public health measure. [ABSTRACT FROM AUTHOR]

Glycaemic control is of one the main goals for managing type 2 diabetes. In sub-Saharan Africa and the Democratic Republic of the Congo, studies have reported alarming poor control rates. Patients with poor glycaemic control are exposed to complications leading to high cost of care and deteriorated quality of life. In recent studies by our group, we have demonstrated that poor glycaemic control is high and driven by proximal (individual) and distal (structural) factors in Kinshasa, Democratic Republic of the Congo. Financial constraints impacted many aspects of care at multiple levels from the Government to persons living with diabetes. Financial constraints prevented good preparation, organization and access to diabetes care. Difficulties in implementing lifestyle changes, lack of health literacy and limited healthcare support were also contributing to poor glycaemic control. Through a Delphi study, a group of experts reached a consensus on five potential strategies for improving glycaemic control in the Democratic Republic of Congo as follows: changing the healthcare system for better diabetes care extended to other noncommunicable diseases, ensuring consistent financing of the healthcare, augmenting the awareness of diabetes among the general population and the persons living with diabetes, easing the adoption of lifestyle modifications and reducing the burden of undiagnosed diabetes. This paper reflects on the urgent need for an improved management framework for diabetes care in the Democratic Republic of the Congo. Specifically, the Government needs to increase the investment in the prevention and treatment of noncommunicable diseases including diabetes. [ABSTRACT FROM AUTHOR]

Health literacy research is growing rapidly and broadly; however, conceptual advances in critical health literacy (CHL) seem hampered by a lack of a clear definition. In this paper, we refer to key features of the concept as identified in earlier works, offer a new definition of CHL and briefly discuss its theoretical roots. Reflection and action are suggested as the two constituent components of CHL. Consequences for future research are also discussed. [ABSTRACT FROM AUTHOR]

The compassionate community movement as both a public health approach and a social model of care for various life stages is gaining traction in Canada and elsewhere. One example is the Windsor-Essex Compassion Care Community (WECCC), an evidence-based model and set of tools to improve the quality of life, health and wellness of vulnerable and aging populations by identifying and addressing upstream and downstream social and other risks to physical and mental health. This paper presents findings from the WECCC pilot evaluation. The WECCC initiative provided one-on-one volunteer-supported quality of life assessment, resource navigation and goals support program (Catalyzing Community Connections). This was augmented with public education sessions on social connection and loneliness (Importance of Being Connected) for the broader population. The RE-AIM framework was used to frame evaluation of WECCC through the first 4 years. Questionnaires were used to evaluate participant outcomes related to implementation and effectiveness. Interviews and focus groups were completed to understand impacts. From 2017 to 2020, WECCC has engaged over 2,500 individuals, 65 organizations and 400 volunteers combined in both programs. Nearly all (82% to 95%) participants reported positive changes to health, quality of life and/or social connections. This developmental phase of a compassionate community initiative has allowed piloting of an evaluation framework focusing on reach, adoption, implementation and early signals of effectiveness and maintenance. This demonstration provides information on feasibility, acceptability and potential impacts of this type of over-arching community initiative. [ABSTRACT FROM AUTHOR]

The Ottawa Charter laid the ground work for a new research and practice agenda by urging health promoters to advocate for healthy public policies. After more than 20 years, it is now time to reflect on the state of policy research in health promotion and to examine how rigorously theories are applied. The review of the literature was conducted on 11 peer-reviewed journals. The journals were selected for their solid track record in publishing health promotion articles and by using a set of pre-defined inclusion and exclusion criteria. The articles, published between January 1986 and June 2006, were searched using Medline and CINAHL databases. The selected papers feature search terms related to ‘politics’, ‘policy’, ‘advocacy’ and ‘coalition’. We examined the theoretical grounding of each paper and whether it focuses on policy content (e.g. nature, impact, evolution of the policy), policy processes (e.g. advocacy capacity building and strategies) or theoretical/methodological issues in policy analysis. This review demonstrates that policy research in health promotion is still largely an a-theoretical enterprise. Out of the 119 articles that were found eligible, 39 did apply to some degree a theoretical framework, of which 21 referred to a theoretical framework from political science. We conclude that the field has yet to acknowledge critical concepts that would help to shed light on the policy process, and that validated rigorous theoretical frameworks to inform research and practice are hardly applied. Recommendations are formulated to improve policy research in health promotion. [ABSTRACT FROM AUTHOR]

The cognitive and social practices associated with critical health literacy, such as critical appraisal of health messages and participation in political processes to address wider determinants of health, are of lifelong benefit. Understanding how and where critical health literacy development can be supported early in the life course may improve health outcomes now and in the future. This scoping review focuses on how critical health literacy in children is conceptualized and the supportive environments available for its development. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines are used in reporting. Evidence retrieved was eligible for inclusion if it contained a substantive conceptual or empirical study of critical health literacy in populations aged 7–11 (middle childhood). From the included 18 peer-reviewed and grey literature sources, schools are identified as the setting most associated with the development of critical health literacy in the target age group. However, the action-oriented dimension of critical health literacy is rarely supported in the school setting. The review concludes that further research is needed to clarify how and where to support children to develop critical health literacy in and outside of school settings. [ABSTRACT FROM AUTHOR]

This article proposes to advance the connections between salutogenic theory and assets models for health improvement. There is a need to integrate their use in public health and health promotion so that their respective potentials can be fully developed. This requires their synergies to be made more explicit so that a more coherent approach can be taken to their utilization. A mechanism is therefore needed that helps to raise awareness of them and their value as a resource together. Bronfenbrenner's bioecological theory provides one framework that can support better integration of salutogenesis with the applied nature of assets-based models. This paper proposes a new 'synergy model for health' that integrates key concepts associated with salutogenic theory—generalized and specific resistance resources (GRRs/SRRs) and generalized and specific resistance deficits and the sense of coherence (SOC). In doing so, it highlights those GRRs and SRRs which are assets that, either individually or collectively, help to develop a stronger SOC. Higher levels of SOC can then support the transformations of potential resources into available assets (that people can understand, manage and make sense of), capable of producing positive health development. The proposed 'Synergy model of health' aims to contribute to a deeper theoretical understanding of health and development through the integration of the key elements of both salutogenesis and assets models. This can facilitate a better contextualization of the ideas into public health policy and practice by making the salutogenic theory more action-oriented and the assets model more theoretical. [ABSTRACT FROM AUTHOR]

This paper reports the results of formative and outcome evaluation of two ongoing community-based intervention programmes for integrated non-communicable disease (NCD) prevention and control in urban low-income settings of Ballabgarh near New Delhi, India, and in Depok, West Java Province of Indonesia. At both sites, a coalition of community members facilitated by academic institution and the World Health Organization, planned and implemented the intervention since 2004. The intervention consisted of advocacy and mediation with stakeholders, training of volunteers and school teachers, communication campaigns, risk assessment camps and reorientation of health services. The formative evaluation was based on the review of documents, and outcomes were assessed using the standardized surveys for NCD risk factors in 2003–2004 and 2006–2007. The baseline surveys showed that tobacco use, low intake of fruits and vegetable, suboptimal levels of physical activity and obesity were prevalent in both the communities. A frequent change in local administrators and lack of perceived priority for health and NCDs limited their involvement. Pre-existing engagement of community-based organizations and volunteers in health activities facilitated its implementation. The reach of the programme among the population was modest (25–32%). Health system interventions resulted in increased diagnosis and better management of NCDs at health facilities. Early outcome measures showed mixed results of change in different risk factors. The experiences gained are being used in both countries to expand and provide technical support to national efforts. This paper adds to the knowledge base on the feasibility of designing and implementing large-scale community-based interventions for integrated prevention of NCDs through modification of risk factors. [ABSTRACT FROM AUTHOR]

The global aging demographic is putting pressure on state-delivered health and social care services. As the austerity agenda in the UK cuts state-funded service provision for older people despite increasing demand, social enterprise has become a politically and economically attractive model for the sustainable delivery of some public services. Yet little is known about the impact of social enterprise on the health and wellbeing of older people. In this paper we address this gap in understanding and consider social enterprise activities as complex public health-promoting interventions. Our study aimed to understand what impact social enterprise activities had on the health and wellbeing of participants aged over 50, and also how that impact was created. To achieve this, we conducted qualitative semi-structured interviews with a sample (n = 43) of staff, volunteers, clients and carers aged over 50 who were involved in activities delivered by three social enterprises. Using a thematic analysis to explore manifest and latent themes, two antecedents of subjective younger age emerged explaining how benefit was created, namely downward social comparison and identity. The social enterprise activities we studied benefited participants' health and wellbeing, impacting positively on participants' sense of purpose, social support, connectedness and inclusion. These health and wellbeing benefits can be considered as outcomes of complex public health interventions for older people, and we relate these outcomes to beneficial conditions within the intermediary social determinants of health. We conclude by discussing the future impact of social enterprise activities and current UK policy on the structural determinants of health. [ABSTRACT FROM AUTHOR]

Research using salutogenic factors to promote health is extensive. Salutogenesis, and its core concept 'sense of coherence' (SOC), is a resource-oriented theory and framework, applicable in different contexts. Research combining health promotion and doctoral supervision in higher education is scarce. This article places research supervision in a broader context of sustainable working life by focusing on stress management. It is about health promotion in an area of research supervision, a new approach not described earlier. Research on supervision in general is extensive, focusing on co-generative mentoring, counselling and coaching. A new salutogenic model, 'The Collegial Model', is presented as an example of practical application. The aim of the present article is to introduce and discuss how the salutogenic theory and model of health can be applied to research supervision of postgraduate students. Knowledge about how SOC impacts health and learning has benefit from a systematic review on salutogenic research covering published papers from 1992 to 2003 and until today. 'The Collegial Model' examines fundamental characteristics of supervision related to ethics and sense of coherence: relations, communication, processes, reciprocity, reflection, learning, comprehensibility, manageability, meaningfulness and coherence. Principles for carrying out supervision 'the salutogenic way' are suggested. The conclusion is that doctoral supervision involves mutual learning processes between colleagues in the supervisory team. Supervision has to be theory driven, implying that supervisors could benefit from applying a salutogenic way of thinking and working, particularly in development of guidelines for research supervision. [ABSTRACT FROM AUTHOR]

Holism is an ancient theme concept that has resurfaced in recent literature, and that requires informed and intentional use in order to preserve its utility. This paper provides a historical and conceptual reintroduction of the notion of holism as it relates to health, with the hopes of informing the term's use in public health discourse. It also addresses the challenges that a lack of conceptual clarity about holistic health imposes on public health and health promotion discussions. It describes how the use and conceptualizations of holism are shifting in health promotion and argues that failing to accurately define and delineate its scope risks diluting its utility for future health promotion applications. We address these two problems, and build an argument for a rediscovery of the theory of holism in public health and health promotion, globally. [ABSTRACT FROM AUTHOR]

More than 20 years ago an article about the use of drawings in higher education appeared in a medical journal. After that, other papers explored the possible contribution of drawings in adult education, while only very few in the field of health promotion and education. This article aims to introduce the use of drawing in this field using the salutogenic lens to think, plan and reflect on academic learning. Reflections on what salutogenesis is and what we can consider a clear application of salutogenic principles to the learning process answer a hypothetical question for the reader concerning the relationship between drawings and health promotion theories. They appear as communication tools capable of exploring meaning-making processes, capturing data that is flexible to dynamic systems, power relations, as well as emotional and latent aspects of human experience. This article proposes a connection between salutogenesis and drawings through: a theoretical framework on salutogenic learning and drawings; a teacher practice and its tools focusing the critical point on visual data analysis in a learning environment; a learner case example for knowledge and capacity building through the drawing process; and a health promotion competency-based analysis. Our case example illustrates how drawings were introduced in a post-graduate course in Health Promotion and Education and argues their strengths and weaknesses. [ABSTRACT FROM AUTHOR]

Social norms can greatly influence people's health-related choices and behaviours. In the last few years, scholars and practitioners working in low- and mid-income countries (LMIC) have increasingly been trying to harness the influence of social norms to improve people's health globally. However, the literature informing social norm interventions in LMIC lacks a framework to understand how norms interact with other factors that sustain harmful practices and behaviours. This gap has led to short-sighted interventions that target social norms exclusively without a wider awareness of how other institutional, material, individual and social factors affect the harmful practice. Emphasizing norms to the exclusion of other factors might ultimately discredit norms-based strategies, not because they are flawed but because they alone are not sufficient to shift behaviour. In this paper, we share a framework (already adopted by some practitioners) that locates norm-based strategies within the wider array of factors that must be considered when designing prevention programmes in LMIC. [ABSTRACT FROM AUTHOR]

This paper presents the methodology, programme logic and conceptual framework that drove the evaluation of the Fifth Phase of the WHO European Healthy Cities Network. Towards the end of the phase, 99 cities were designated progressively through the life of the phase (2009-14). The paper establishes the values, systems and aspirations that these cities sign up for, as foundations for the selection of methodology. We assert that a realist synthesis methodology, driven by a wide range of qualitative and quantitative methods, is the most appropriate perspective to address the wide geopolitical, demographic, population and health diversities of these cities. The paper outlines the rationale for a structured multiple case study approach, the deployment of a comprehensive questionnaire, data mining through existing databases including Eurostat and analysis of management information generation tools used throughout the period. Response rates were considered extremely high for this type of research. Non-response analyses are described, which show that data are representative for cities across the spectrum of diversity. This paper provides a foundation for further analysis on specific areas of interest presented in this supplement. [ABSTRACT FROM AUTHOR]

The process of generating evidence-based public health interventions is understood to include steps that define the issue, generate and test solutions in controlled settings, replicate and then disseminate more widely. However, to date models have not considered the types and scale of formative evaluation tasks that are needed to up-scale interventions, from efficacy to population-wide dissemination in the real world. In this paper, we propose that an additional stage of ‘translational formative evaluation’ is necessary for the translation of effectiveness evidence into wide-scale public health practice. We illustrate the utility of translational formative evaluation, through a case study of the Get Healthy Information and Coaching Service® (GHS), a population-based telephone service designed to assist adults change lifestyle-related behaviours. The additional translational formative evaluation steps comprised synthesis of efficacy studies, qualitative research with the wider target audience, environmental analysis and stakeholder consultation. They produced precise recommendations to refine GHS design and implementation. Translational formative evaluation is a necessary intermediate step, following efficacy studies and a precursor to population-wide implementation of public health programmes. [ABSTRACT FROM AUTHOR]

Climate change poses serious threats to human health and well-being. It exacerbates existing health inequities, impacts on the social determinants of health and disproportionately affects vulnerable populations. In the Australian region these include remote Aboriginal communities, Pacific Island countries and people with low incomes. Given health promotion's remit to protect and promote health, it should be well placed to respond to emerging climate-related health challenges. Yet, to date, there has been little evidence to demonstrate this. This paper draws on the findings of a qualitative study conducted in Victoria, Australia to highlight that; while there is clearly a role for health promotion in climate change mitigation and adaptation at the national and international levels, there is also a need for the engagement of health promoters at the community level. This raises several key issues for health promotion practice. To be better prepared to respond to climate change, health promotion practitioners first need to re-engage with the central tenets of the Ottawa Charter, namely the interconnectedness of humans and the natural environment and, secondly, the need to adopt ideas and frameworks from the sustainability field. The findings also open up a discussion for paradigmatic shifts in health promotion thinking and acting in the context of climate change. [ABSTRACT FROM AUTHOR]

Health services continue to be seen as significant settings for health improvement, and developments continue to be made in the nature of such work, means of optimal delivery and outcomes. This paper builds on previous work by reporting on activity in a series of sites within ‘NHS Health Scotland's (NHS HS)’ Health Promoting Health Service (HPHS) initiative. The objectives of the review were to: describe the achievements of HPHS sites, assess the degree of influence and embedding of the HPHS approach, review the support functions provided by ‘NHS HS' and identify the challenges to implementation and sustainability. The review identified a variety of activity associated with HPHS, ranging from a topic focused/behaviour change approach to efforts to re-orientate organizational features. The role that NHS HS played in developing settings capacity was largely endorsed, and there was, despite the existence of some barriers, evidence that HPHS was being successfully embedded within health service organizational policies and procedures. In particular, the role of a national level strategic guidance document to NHS CEOs [‘Chief Executive Letter (14)'] is noted as having been significant in creating a conducive context for HPHS. In this context, the paper concludes by reflecting more broadly on the current status of settings-based health improvement and suggests that on the basis of this review there should be optimism in pursuing a relatively expansive vision of health improvement in this particular setting and potentially others. [ABSTRACT FROM AUTHOR]

Globally, the mental health system is being transformed into a strengths-based, recovery-oriented system of care, to which the concept of active living is central. Based on an integrative review of the literature, this paper presents a heuristic conceptual framework of the potential contribution that enjoyable and meaningful leisure experiences can have in active living, recovery, health and life quality among persons with mental illness. This framework is holistic and reflects the humanistic approach to mental illness endorsed by the United Nations and the World Health Organization. It also includes ecological factors such as health care systems and environmental factors as well as cultural influences that can facilitate and/or hamper recovery, active living and health/life quality. Unique to this framework is our conceptualization of active living from a broad-based and meaning-oriented perspective rather than the traditional, narrower conceptualization which focuses on physical activity and exercise. Conceptualizing active living in this manner suggests a unique and culturally sensitive potential for leisure experiences to contribute to recovery, health and life quality. In particular, this paper highlights the potential of leisure engagements as a positive, strengths-based and potentially cost-effective means for helping people better deal with the challenges of living with mental illness. [ABSTRACT FROM AUTHOR]

The factors underlying poor child health in remote Australian Indigenous (Aboriginal and Torres Strait Islander) communities are complex. There is a lack of consistent and reliable information that allows: (i) the identification of priorities or areas of particular need at household and community levels; (ii) monitoring progress over time; and (iii) the assessment of the impact of interventions. This paper describes the process and methods used to identify the factors that underlie high rates of poor child health in remote Aboriginal communities in the Northern Territory (NT). This work has led to the development of indicators and tools suitable for use within a continuous quality improvement programme. Indigenous and non-Indigenous individuals from a range of disciplines and backgrounds participated in study activities. This allowed for a range of perspectives, including scientific, lay and Aboriginal perspectives, to be accommodated and reflected in study outcomes and outputs. Study participants identified a wide range of physical and social factors that they believe underlies poor child health in remote Aboriginal community contexts in the NT. The approach taken in this study provides some confidence that the indicators developed will be seen as meaningful and appropriate by the residents of remote communities and key stakeholders. Two tools have been developed and are now in use in the practice setting. One assesses social determinants of health at the community level, for example water supply, food supply. The second applies to individual households and assesses the social and environmental indicators that are recognized as placing children at greater risk of poor health and development outcomes. [ABSTRACT FROM AUTHOR]

This research aimed to understand how the policy was represented as a 'problem' in food regulatory decision-making in Australia, and the implications for public health nutrition engagement with policy development processes. Bacchi's 'what's the problem represented to be?' discourse analysis method was applied to a case study of voluntary food fortification policy (VFP) developed by the then Australia and New Zealand Food Regulation Ministerial Council (ANZFRMC) between 2002 and 2012. As a consultative process is a legislated aspect of food regulatory policy development in Australia, written stakeholder submissions contributed most of the key documents ascertained as relevant to the case. Four major categories of stakeholder were identified in the data; citizen, public health, government and industry. Predictably, citizen, government and public health stakeholders primarily represented voluntary food fortification (VF) as a problem of public health, while industry stakeholders represented it as a problem of commercial benefit. This reflected expected differences regarding decision-making control and power over regulatory activity. However, at both the outset and conclusion of the policy process, the ANZFRMC represented the problem of VF as commercial benefit, suggesting that in this case, a period of 'formal' stakeholder consultation did not alter the outcome. This research indicates that in VFP, the policy debate was fought and won at the initial framing of the problem in the earliest stages of the policy process. Consequently, if public health nutritionists leave their participation in the process until formal consultation stages, the opportunity to influence policy may already be lost. [ABSTRACT FROM AUTHOR]

There is a substantial and growing burden of premature mortality caused by non-communicable diseases (NCDs) globally. This paper evaluates the preventive efforts of the WHO European Healthy Cities Network during its fifth phase (2009-13), specifically for four behavioural risk factors (tobacco use, alcohol abuse, unhealthy diet and physical inactivity). Drawing on case studies, questionnaire responses and other materials, it notes which cities were involved, what worked and did not, the triggers for action, challenges met and lessons learnt. Few cities appeared to have taken comprehensive approaches to NCD prevention across multiple risk factors, or have combined population- and individuallevel interventions.Work on healthy food and diet predominantly focused on children in educational or care settings, and few cities appeared to take a comprehensive approach to tackling obesity. Partnerships were a strong feature for all the NCD risk factor work, and were frequently extensive, being most diverse for the Healthy Diet and Food work. There were strong examples of engagement with communities, also involved in co-designing and shaping projects. Equity also featured strongly and there were multiple examples of how attention had been paid to the social determinants of health. There was evidence that cities continue to be significant innovative forces within their countries and drivers of change, and the mutual dependency of the national and local levels was highlighted. Interventions to promote physical activity have shifted focus from specific events and projects to being more integrated with other policy areas and based on intersectoral collaboration. [ABSTRACT FROM AUTHOR]

Engaging in outdoor nature-based spaces has significant positive physiological and psychological health benefits. Although the integration of nature into indoor spaces is rarely considered a health-promoting tool, it may be an effective method for increasing nature engagement in a largely urbanized world. This paper presents an overview of indoor nature exposure (INE) by summarizing the current evidence of INE through the use of a scoping methodology. Results show that INE can be a health-promoting tool through the interaction of nature-based stimuli and individual characteristics (e.g. gender, age). Moreover, the results of the current literature need to be interpreted with consideration to methodological issues, such as the lack of participant characteristics, the issue of exposure realism and little qualitative data to highlight individual experiences. The scoping review process allowed for the summation of results and for a framework to be created in order to better understand how INE is facilitated. [ABSTRACT FROM PUBLISHER]

Health literacy has gained momentum in the Western world, yet in Europe the concept of health literacy is only marginally integrated in research, policy and practice. The present paper presents how translation may act as an influential factor with regard to integration of the health literacy notion in Europe. This study has compared five data sources that provide translations of health literacy: The European Union's Health Strategy; the translations applied in the European Health Literacy Project; national health expert opinions and Google Translate. The comparison integrated Peter Fawcett's translation techniques as a framework for analysis. The results showed a total of 28 translations: 22 from the European Union Health Strategy; 6 from the HLS-EU project; 17 from experts; 25 from Google Translate. Some countries are consistent in translations of health literacy, other countries diverge, the reasons being that health literacy is not yet mainstreamed and the translations are primarily driven by a latent polarized discourse of the concept of literacy. The study showed that translations in general reveals enriched insights in the cohesion of health literacy as one notion and provides the European Health Literacy Glossary that can inform health professionals, academia and decision-makers to further advance health literacy across Europe. [ABSTRACT FROM AUTHOR]

Type 2 diabetes is highly prevalent among South Asian origin groups around the world. Not only is prevalence higher than in other ethnic groups, age at presentation is lower and these groups are more likely to experience complications. Evidence suggests that lifestyle interventions may prevent or delay the onset of diabetes. However, little is known about diabetes prevention in South Asians (SA). DH!AAN is a diabetes prevention program designed for Surinamese SA in The Netherlands. In this paper, we describe the theoretical frameworks and formative research that guided the development and cultural adaptation of DH!AAN. Cultural adaptation was based on analysis of the determinants of diet and physical activity, including socio-cultural factors, within our study population. This led to the incorporation of surface and deep structure elements in the intervention. One-to-one counseling by dieticians using motivational interviewing (MI) was the basis for the intervention. Additionally, we aimed to generate social support by including family members in parts of the intervention and group sessions to address issues relating to traditional food habits. We discuss our reflections on the development process and the choices made in developing this intervention. The results of DH!AAN will provide insight into the use of MI for this population group. Moreover, DH!AAN will provide evidence regarding the feasibility of diabetes prevention among South Asian populations. [ABSTRACT FROM AUTHOR]

To compare the use of health impact assessment (HIA) and the decision-making triangle (DMT) framework for evidence-informed, ethics-based decision-making and consider implications for practice. We compared HIA and the DMT approach with reference to: their use of evidence and theory; their application of ethical principles or values; and how they aid decision-making. A good fit between the HIA and DMT approaches was found. Ways in which they could be of benefit to each other were identified. The DMT approach and HIA are highly compatible: they are rooted in largely shared ethical principles or values; both involve appropriate use of evidence and theory; and both are concerned with enhancing the quality of decision-making in the interests of population health. The DMT approach and HIA are of potential value to each other: established HIA methods and tools can be of practical help in using the DMT approach; and the DMT framework provides insights to how HIA methods and processes could be improved and the vision of ‘impacts that matter’ widened. [ABSTRACT FROM AUTHOR]

The Community Health and the Built Environment (CHBE) project investigated the role of place in interventions for chronic disease prevention in order to identify contextual factors that may foster or inhibit intervention success. This paper presents a project model comprising objective-outsider and subjective-insider perspectives in a multi-method, community-based participatory research approach with an emphasis on knowledge exchange. The collaborative process generated valuable lessons concerning effective conduct of community-based research. The CHBE project model contributes a mechanism for investigating how place influences health behaviours and the outcomes of health promotion interventions. [ABSTRACT FROM PUBLISHER]

Health promotion addresses issues from the simple (with well-known cause/effect links) to the highly complex (webs and loops of cause/effect with unpredictable, emergent properties). Yet there is no conceptual framework within its theory base to help identify approaches appropriate to the level of complexity. The default approach favours reductionism—the assumption that reducing a system to its parts will inform whole system behaviour. Such an approach can yield useful knowledge, yet is inadequate where issues have multiple interacting causes, such as social determinants of health. To address complex issues, there is a need for a conceptual framework that helps choose action that is appropriate to context. This paper presents the Cynefin Framework, informed by complexity science—the study of Complex Adaptive Systems (CAS). It introduces key CAS concepts and reviews the emergence and implications of ‘complex’ approaches within health promotion. It explains the framework and its use with examples from contemporary practice, and sets it within the context of related bodies of health promotion theory. The Cynefin Framework, especially when used as a sense-making tool, can help practitioners understand the complexity of issues, identify appropriate strategies and avoid the pitfalls of applying reductionist approaches to complex situations. The urgency to address critical issues such as climate change and the social determinants of health calls for us to engage with complexity science. The Cynefin Framework helps practitioners make the shift, and enables those already engaged in complex approaches to communicate the value and meaning of their work in a system that privileges reductionist approaches. [ABSTRACT FROM PUBLISHER]

This paper provides an overview of five key internationally recognized health promotion frameworks and assesses their consideration of gender. This analysis was conducted as part of the Promoting Health in Women project, a Canadian initiative focused on generating a framework for effective health promotion for women. To date, no review of health promotion frameworks has specifically focused on assessing the treatment of gender. This analysis draws on a comprehensive literature review that covered available literature on gender and health promotion frameworks published internationally between 1974 and 2010. Analysis of five key health promotion frameworks revealed that although gender was at times mentioned as a determinant of health, gender was never identified and integrated as a factor critical to successful health promotion. This superficial attention to the role of gender in health promotion is problematic as it limits our capacity to understand how gender influences health, health contexts and health promotion, as well as our ability to integrate gender into future comprehensive health promotion strategies. [ABSTRACT FROM AUTHOR]

In spite of improvements in global health over the 20th century, health inequities are increasing. Mounting evidence suggests that reducing health inequities requires taking action on the social determinants of health (SDOH), which include income, education, employment, political empowerment and other factors. This paper introduces an alternative health education curriculum, developed by the US-based non-profit organization Just Health Action, which teaches critical health literacy as a step towards empowering people to achieve health equity. Critical health literacy is defined as an individual's understanding of the SDOH combined with the skills to take action at both the individual and the community level. Prior to describing our curricular framework, we connect the recommendations of the World Health Organization Commission on the SDOH with the objectives of the Ottawa Charter for Health Promotion by arguing that achieving them is reliant on critical health literacy. Then we describe our four-part curricular framework for teaching critical health literacy. Part 1, Knowledge, focuses on teaching the SDOH and the paradigm of health as a human right. Part 2, Compass, refers to activities that help students find their own direction as a social change agent. Part 3, Skills, refers to teaching specific advocacy tools and strategies. Part 4, Action, refers to the development and implementation of an action intended to increase health equity by addressing the SDOH. We describe activities that we use to motivate, engage and empower students to take action on the SDOH and provide examples of advocacy skills students have learned and actions they have implemented. [ABSTRACT FROM AUTHOR]

This paper focuses on dissemination of the healthy schools (HS) approach in the province of Quebec, Canada. Dissemination aims at raising awareness about HS and promoting its adhesion among actors concerned with youth health in school. As HS is a joint initiative based on agreement and collaboration between health and educational sectors, the positions of stakeholders that foster cooperation between these sectors were considered to be critical to optimize its dissemination. The study's objectives were to: (i) examine and contrast the stakeholders' conceptions of HS and (ii) understand how converging and diverging stakeholders' positions on HS favourably or negatively influence its dissemination in Quebec. Gray's analytical approach to collaboration and its focus on stakeholders' mindframe about a domain served as a conceptual lens to examine stakeholders' positions regarding HS. Collection methods included documentary analysis and semi-structured interviews of 34 key internal and external informants at the provincial, regional and local levels. The results showed consensual adhesion to fundamental principles of the HS approach. However, differences in conceptualization between provincial authorities of the two sectors concerning the way to disseminate HS have been observed. These differences represented a significant barrier to HS optimal dissemination. A dialogue between the two authorities appears to be essential to arrive at a negotiated and shared conceptualization of this issue in the Quebec context, thus allowing agreements for adequate support. The results may serve as the basis for a more fruitful dialogue between actors from the two sectors, at different administrative levels. [ABSTRACT FROM AUTHOR]

Adherence and participation can be improved in health programs for older people with concerns about falling. While health literacy empowers older people to have greater control over their health, little is known about the extent to which health literacy influences health behaviours associated with concerns about falling in older people. This study aimed to synthesise current findings on health literacy, concerns about falling and falls to propose a multicomponent theoretical model on health literacy and concerns about falling. The model was developed based on a review of the literature, existing frameworks and models on health literacy and concerns about falling. Existing evidence on the relationship between health literacy and concerns about falling in older people is limited. Evidence from other research areas, however, shows that health literacy is closely related to many of the determinants of concerns about falling. More research is needed to clarify the impact of health literacy on intervention adherence and decision-making processes of older people with concerns about falling. Our model offers a novel perspective on the role of health literacy in health behaviours associated with concerns about falling, suggesting new research directions and providing insights for clinicians to consider health literacy when managing older patients with concerns about falling. [ABSTRACT FROM AUTHOR]

New interventions are offered to children of divorced parents in Danish schools. Establishing conversation groups can be seen as part of this overall effort to increase pupils' well-being. This new practice leads to new professional challenges when teachers facilitate group processes and call for in-depth studies of children's own perspectives on their participation in these interventions. This article is based on ethnographic fieldwork and asks the following research question: 'How do children make sense of the professionals' double role as both group leader and teacher when facilitating the conversation-groups in schools?' The study draws on 23 interviews with children and observations in four conversation groups in Denmark. Theory of social representations is used as an analytical tool to explore the dilemmas of school interventions for children of divorced parents. The analysis presents three dominant themes: the group leader's problematic double role , balancing the duty of confidentiality and trusting the group members. The analysis shows that children struggle to express feelings about their home situation in the school context. The importance of balancing the duty of confidentiality as a group leader is clearly reflected as a key factor, seen from the perspective of the child. [ABSTRACT FROM AUTHOR]

Current international attention to Health in all policies (HiAP) has its origins in a more sophisticated understanding of the impact of public policies on health, and a recognition that policies across government have an impact on the social and environmental determinants of health and related inequalities in health. As an emerging field, there has been limited attention focused on comprehensive approaches to the evaluation of HiAP to date, and the research focus around HiAP has mainly examined the processes of cross-sectoral policy development, rather than their health-related impacts or outcomes. The purpose of this paper is to explore issues in assessing the implementation of HiAP and describe an expanded evaluation framework for assessing the potential intermediate and end-point effects of HiAP actions, using a planning logic model for ‘complex programs’. This meets the needs of public sector policy-makers who express an interest in understanding the relationship between HiAP and health-related and social outcomes. The paper proposes applying a contribution analysis method to estimate and model the anticipated impacts of HiAP policies on intermediate and longer term outcomes, in advance of empirical studies of these outcomes, and as an innovative input into HiAP and evaluation planning. A broader long-term evaluation framework will enhance the political saliency of HiAP initiatives, especially from governments considering HiAP approaches in financially constrained environments. [ABSTRACT FROM PUBLISHER]

This article highlights the significance of prioritizing Indigenous voices and knowledge systems, using whānau-centred initiatives (a concept that encompasses the broader family and community) as a foundation for health promotion within an Indigenous context. Tū Kahikatea, a conceptual framework, is used to demonstrate the relationship between the values underpinning different whānau-centred initiatives and their corresponding outcomes. The framework highlights the capacity of whānau-centred initiatives to support whānau in attaining mana motuhake, which represents collective self-determination and the ability to exercise control over their own future. By doing so, these initiatives contribute to the improvement of whānau health outcomes. With recent changes to Aotearoa New Zealand's health system, the findings underscore the benefits and potential of whānau-centred initiatives in enhancing whānau health outcomes, and advocate for continued strengths-based practices in Aotearoa New Zealand's health system. By bridging the gap between academia and grassroots community action, the article demonstrates the potential of whānau-centred initiatives and contributes to a global call for integrating Indigenous viewpoints and practices into Westernized healthcare, in order to improve Indigenous health outcomes. [ABSTRACT FROM AUTHOR]

Acquisition of health promotion (HP) skills and knowledge is essential for interventions development in this field. In sports clubs (SC), little HP training exists even though it was requested by SC actors. In response, the PROSCeSS (PROmotion de la Santé au sein du Clubs SportifS) MOOC (Massive Open Online Course) was developed to support actors of HP in the SC in the development of HP interventions. The present study evaluates the MOOC's effectiveness and learning process. The RE-AIM framework, measuring reach, effectiveness, adoption, implementation and maintenance was used to structure this study. Surveys were sent before and after the MOOC to the 2814 learners. Among the 502 (18%) respondents to the pre-survey, 80% reported belonging to a SC as a coach (35%) or manager (25%). The 14% of pre-survey respondents who completed the post-survey increased their HP knowledge score by 42% and their confidence to implement HP actions by 6%. Results present the strategies considered most important and feasible by the learners and the main barriers to the implementation of HP actions in the SC. This study shows that MOOC appears to be an appealing (93% of learners were satisfied) and effective solution (as long as it is followed) to develop HP knowledge and skills of SC actors in HP, meeting their needs and constraints. Although improvements should be made (especially in terms of promoting adoption), this type of educational format should be encouraged to support the HP potential of SC. [ABSTRACT FROM AUTHOR]

Innovative actions are local initiatives which leverage the interactions between the ocean and human health to reduce the risks and enhance the benefits for the stakeholders and the natural environment. These initiatives can have strong positive effects on human health and wellbeing as well as on the marine environment. We analysed 150 such innovative actions in Europe. Using a combined case study and survey approach, innovative actions were identified using interviews and content analysis of websites and compiled into a database. Quantitative data were analysed according to the Drivers, Pressures, State, Impact and Response (DPSIR) framework, guided by selected in-depth interviews. Overall, the innovative actions provided a positive impact on the health of both the ocean and humans through increasing food provision, water quality and tourism opportunities; and addressing environmental issues such as commercial fish stock depletion, pollution and climate change. Innovative actions contributed to meeting various targets of the Sustainable Development Goals (SDGs) 3, 13 and 14. These actions played a potential role ahead of and alongside policy. Some of the innovative actions may have potential to be put in place elsewhere. Such up-scaling would need to be adapted to local circumstances and could be facilitated by an innovative action exchange platform. [ABSTRACT FROM AUTHOR]

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel virus in the coronavirus family, causing the coronavirus disease (COVID-19). Biomedical vaccines are key but alongside biomedical vaccines, a social vaccine can be similarly useful to prevent infection from SARS-CoV-2, if applied as a health promotion strategy. In order to slow down and control the spread of SARS-CoV-2, applying the social vaccine concept should be considered in parallel. From a health promotion perspective, a social vaccine is a process of social and political mobilization driven by governmental and non-governmental organizations aiming at populations by applying interventions such as health communication, education and mass media campaigns as well as determinant-based programs to address environmental factors influencing personal behavior and community capacities to cope with and overcome the societal burdens of COVID-19. In this context, health literacy is significant, as seen in the role it plays in empowering citizens during the COVID-19 pandemic and enabling them to deal with health information considering COVID-19. As a public health strategy, health literacy as a social vaccine will enable individuals and communities to mitigate the spread of the virus by understanding and applying information as provided through governments and health authorities. The aim of this article is to explore health literacy as a promising social vaccine and opportunity to utilize social vaccination and thus be considered as a key public health approach—both bottom-up and top-down—to support the combat of COVID-19 and future states of emergency. [ABSTRACT FROM AUTHOR]

Access to appropriate healthcare among disadvantaged populations in countries with universal healthcare requires a critical understanding of the relationships between poverty, social exclusion and health in the local context. The qualitative study explored the experiences of healthcare utilization in an inner-city impoverished community living in slum conditions in Hong Kong. Interviews with 40 slum residents in one of the poorest neighbourhoods in the city explored the following domains: experience and perceptions of the community, housing conditions, informal social capital and support system, interactions with community workers, and experiences in utilizing social and healthcare services. Framework analysis was conducted to identify local themes under the model of healthcare utilization: approachability, acceptability, availability and accommodation, affordability and appropriateness. Despite the subsidized public healthcare system, multiple barriers were identified. Low literacy of healthcare systems was prevalent. Specifically, structural barriers relating mainly to the availability, accommodation and affordability of health services were salient to impede access to healthcare. The barriers related to healthcare providers primarily stemmed from the interactions of healthcare providers, perceived stigma and the lack of patient-centred care. In addition, poverty-related sociocultural norms and personal beliefs of healthcare were found to be significant barriers to healthcare access. Despite the well-established subsidized public healthcare system, healthcare inequity was evident. Lack of quality healthcare access needs to be addressed by providing social and educational resources that facilitate collective efficacy for healthcare, community engagement from public sectors and person-centred care with healthcare providers. [ABSTRACT FROM AUTHOR]

Indigenous Standpoint Theory forms the epistemological foundation for this study and methodological choices were made within this theoretical framework to ensure culturally responsive research processes that engaged the Indigenous agenda of self-determination and rights. The objectives of this research were to determine: (i) Indigenous perceptions of the facilitators and barriers to exercise; (ii) The potential feasibility and sustainability of an exercise intervention. In this context, Participatory Action Research methods were used to design the data-gathering instrument for the study—a questionnaire, co-designed with the Noongar Aboriginal community of Perth, Western Australia. This self-administered questionnaire, distributed to participants by email, post and manual delivery, sought to elicit the factors that impact uptake and retention of regular exercise activities. Questionnaire data included individual demographic detail and specific question responses on labelled 5 point Likert Scales. Specific question responses were tabulated by Likert Scale label category and the response distribution for each question was enumerated. Simple descriptive statistics (measures of central tendency and variance) were used to characterize the data set and the Chi squared test was used to evaluate frequency differences between males and females. A total of 133 participants (71 females) completed the questionnaire. The results indicated that people valued exercise. The most common barriers indicated by participants were exercising with an injury (63%), changing diet (58%), finding time to exercise every day (55%) and exercising the next day with pain from exercising the day before (54%). A larger proportion of males (34%) than females (24%) reported greater ease in finding time to exercise every day (p  < 0.05). Facilitators mainly related to the potential social and community benefits of exercising with other people, preferably in small groups, and the importance of a culturally secure venue. These findings shed light on what a culturally secure exercise programme might involve for the Noongar community. As this may have implications for other Aboriginal and Torres Strait Islander and international First Nations' Peoples, more focused research is needed on the place of traditional physical activities and the nature of culturally secure exercise programmes and spaces to enable wider application. [ABSTRACT FROM AUTHOR]