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Peer reviewed: True, Funder: national institute for health research collaboration for leadership in applied health research and care north west coast; FundRef: https://doi.org/10.13039/501100015509, BACKGROUND: Systems thinking is integral to working effectively within complex systems, such as those which drive the current population levels of overweight and obesity. It is increasingly recognised that a systems approach - which corrals public, private, voluntary and community sector organisations to make their actions and efforts coherent - is necessary to address the complex drivers of obesity. Identifying, implementing and evaluating actions within complex adaptive systems is challenging, and may differ from previous approaches used in public health. METHODS: Within this conceptual article, we present the Action Scales Model (ASM). The ASM is a simple tool to help policymakers, practitioners and evaluators to conceptualise, identify and appraise actions within complex adaptive systems. We developed this model using our collective expertise and experience in working with local government authority stakeholders on the Public Health England Whole Systems Obesity programme. It aligns with, and expands upon, previous models such as the Intervention Level Framework, the Iceberg Model and Donella Meadows' 12 places to intervene within a system. RESULTS: The ASM describes four levels (synonymous with leverage points) to intervene within a system, with deeper levels providing greater potential for changing how the system functions. Levels include events, structures, goals and beliefs. We also present how the ASM can be used to support practice and policy, and finish by highlighting its utility as an evaluative aid. DISCUSSION: This practical tool was designed to support those working at the front line of systems change efforts, and while we use the population prevalence of obesity as an outcome of a complex adaptive system, the ASM and the associated principles can be applied to other issues. We hope that the ASM encourages people to think differently about the systems that they work within and to identify new and potentially more impactful opportunities to leverage change.

Supplementary Material 1

The current pre-registration refers to Work Packages 1 and 2 of the evaluation. The overall study aims to comprehensively evaluate the new ‘unhealthy commodities’ advertisement policy introduced by Bristol Council in 2021/22, but not fully implemented until middle 2022. The aims covered here refer to the quantitative evaluation of the impact of the policy on advertisement exposure and purchasing of unhealthy commodities; information obtain from a repeated resident survey.

Additional file 1: Table S1. Stakeholder topic guide. Table S2. Survey questions HFSS, alcohol and gambling modules. Table S3. Self-reported exposure to different types of adverts by respondent characteristics.

Aims of the Research: This research project aims to collect information on how much people in the city of Bristol and in South Gloucestershire see advertisements for unhealthy products such as junk foods and soft drinks, alcohol, and gambling. It also aims to find out how often they use these products. This is important because Bristol City Council will ban this sort of advertising in the city at the end of 2021. To be able to see if the ban had an effect we need to collect information before and after the implementation of the ban. This research project will collect information before the ban and a larger study, which we hope to conduct in future, will collect further information after the ban. We will then compare the results between the before and after groups. Background of the Research: Research has shown that the more people see adverts for unhealthy products the more they use them, and that this is especially the case for children and young people. People who are on lower incomes are exposed to more unhealthy adverts, including from bus stops and billboards in their neighbourhoods. Some research also suggests that if these adverts are removed, this has a positive effect on people’s behaviours. In 2019 the Mayor of London brought in a new policy to ban adverts for foods and drinks high in fat, sugar and/or salt at any places in London owned by Transport for London (Tfl). A first assessment of this policy shows positive effects on people buying less of the unhealthy products. Bristol City Council will start a similar advertisement ban at the end of 2021, but it will also include alcohol and gambling. This will be the first policy like this outside London. Design and methods used: A survey will be sent to people living in Bristol. It will collect information on exposure to the advertising of unhealthy products and the use of those products. The same survey will be sent to people living in South Gloucestershire so we can compare with a similar area nearby that does not have the same ban. We can then repeat the survey after the ban has started so that we can compare before-and-after results. We will also collect photos from all advertisement sites that will be affected by the ban, as well as those in the area without the ban, so that we can compare real changes in a future evaluation study. In addition we will use Google Streetview to obtain similar images over the time period prior to our photo collection period to obtain better insights in temporal changes in advertisement exposures. Lastly, we will interview people who designed and planned the policy about how it was made and put into practice. Patient and public involvement: This research proposal has been designed with input from the PPI Lead of NIHR Applied Research Collaboration West (ARC West) and with a member of the ARC West PPI group with an interest in this topic. She has agreed to be a co-applicant for this work. She will help with study design, design of the survey, attend study management meetings, and will be active in any publishing of results. If a full evaluation is to be carried out, she will continue to lead the PPI group. Publication of results: We expect the main results in the second study after the ban. However, we will use the information from this first study to find out more about exposure to unhealthy advertising and different incomes or ethnicities in Bristol and South Gloucestershire.

Additional file 2: Online supplement II. Modifications made to Ripple Effects Mapping.

Additional file 1: Online supplement I: Further information related to the process of Ripple Effects Mapping.

Introduction: Engagement denotes the extent to which, and how, individuals and families participate in a weight management (WM) programme. Data suggest that between 8-83% of families do not complete the paediatric WM programme which they initiated, but the underlying mechanisms which drive participant engagement are poorly understood. This thesis aims to 1) establish if participant-and programme-characteristics are associated with various engagement trajectories in paediatric WM programmes, and 2) explain the factors associated with initial-and continued-programme engagement. The Model of Retention – translated from Higher Education – underpins this thesis. Study 1: Methods – Secondary data of 2948 MoreLife participants (age: 10.44±2.80 years, BMI SDS: 2.48±0.87 units, white ethnicity: 70.52 %) were used. Multivariable linear regression and multivariable logistic regression examined the predictors of attendance and engagement groups (e.g. early dropout, late dropout, completion…) respectively. Results – Six variables were associated with engagement (Programme: group size, delivery period, & programme year; Participant: BMI SDS, Ethnicity, & IMD score). Programme characteristics were stronger predictors of engagement than participant characteristics, and the predictors varied between engagement groups. A small proportion of the variance in engagement was explained by the final predictors. Study 2: Methods – Qualitative data were collected from 31 families (parents and children) across three paediatric WM programmes (MoreLife, SHINE, and Weigh To Go) at the early-and late-programme stages. The Model of Retention guided the lines of inquiry and data analysis framework. Results – Six factors were central to engagement: 1) having support; 2) self-efficacy in one’s ability to attend; 3) coping with the demands of programme engagement; 4) controlling engagement decisions; 5) experiencing benefits from engagement; and, 6) having an engagement promoting programme design. The importance and dominance of these factors varied between the early-and lateprogramme stages, and moreover, between parents and children. Conclusions: Participant engagement was demonstrated to be a complex phenomenon; one that is challenging to predict and currently better explained through qualitative investigation. This thesis, and the collective discussion within, illuminate methods of improving WM programme engagement through design and delivery modification. The Model of Retention offers a means of comprehensively explaining engagement. Finally, this thesis provides a conceptual framework for discussing programme engagement.

Additional file 2. JU:MP programme plan. A table providing a description of each of the 15 JU:MP work streams.

Additional file 4. Network mapping survey. A survey to map connections and relationships between different stakeholders and organisations within JU:MP neighbourhoods.

Additional file 3. Influences on behaviour questionnaire. A survey, adapted from Keyworth et al. [42], used to understand the capability, opportunity, motivation and behaviour of neighbourhood-level stakeholders related to supporting children to be physically active.

Additional file 1. Online Supplement I.

Additional file 5. Observational framework. A framework designed to guide the collection and recording of observational data.

Additional file 6. JU:MP thematic framework. The framework used to index data as part of the qualitative framework analysis.

Additional file 1.