The WHO has long emphasised the importance of accelerating the impact of interventions at scale. Sustainable shifts in population behaviours require system-level implementation and embeddedness of large-scale effective health interventions or programs, and yet a minority of efficacious interventions are translated into practice and delivered at a scale sufficient to achieve population-wide effects. On average, men and women of all ages and the majority of adolescents fail to consume the recommended number of serves for any of the nutritious five food group food categories, whereas discretionary food consumption contributes 33 to 36% and 41% to daily energy intake for these population groups, respectively. Only 43% of adults, 29% of children (5–11 years) and 8% of adolescents (12–17 years) achieve government recommended levels of physical activity for health (2011–12). Australia is one of the most overweight developed nations, ranked fifth highest among Organisation for Economic Co-operation and Development countries, with an estimated 67% of adults and one in four children classified overweight or obese. Having a poor diet and low levels of physical activity are leading contributors to the global burden of disease. Obesity and being overweight are leading risk factors for cardiovascular disease, type 2 diabetes, and numerous cancers. Mechanisms identified in this study could potentially be leveraged during future scale up efforts, to positively influence intervention scalability and sustainability.Ĭharacterised by the World Health Organization (WHO) as the ‘epidemic of the 21st century’, obesity remains one of the most serious global public health challenges to date. Current linear, context-to-outcome depictions of scale up oversimplify what is a clearly a complex interaction between perceptions, worldviews and goals of those involved. Future scale up approaches that plan for complexity and encourage iterative adaptation throughout, may enhance scale up outcomes. Our findings challenge current prerequisites for effective scaling suggesting other conditions may be necessary. This paper provides the first evidence for mechanisms underpinning outcomes required for successful scale up of state or nationally delivered interventions. Irrespective of interventions being scaled in similar contexts (e.g., having political favourability) mechanisms still led to both intended and unintended scale up outcomes (e.g., increased or reduced sustainability). Most CMO pathways included ‘intervention attributes’ and led to outcomes ‘community sustainability/embeddedness’ and ‘stakeholder buy-in/perceived value’. All five WHO framework domains were represented in the systems models. Sixty-three CMO pathways underpinned successful scale up, reflecting 36 scale up contexts, 8 key outcomes linked via 53 commonly occurring mechanisms. Twenty-six participants completed surveys 19 completed interviews. Seven interventions were analysed, targeting nutrition ( n = 1), physical activity (n = 1), or a combination ( n = 5). Descriptive statistics were reported for online survey data and realist analysis for interview data. The study involved four distinct phases: Phase 1 expert consultation, database and grey literature searches to identify scaled-up interventions Phase 2 generating initial Context-Mechanism-Outcome configurations (CMOs) from the WHO ExpandNet framework for scaling up Phase 3 testing and refining CMOs via online surveys and realist interviews with academics, government and non-government organisations (NGOs) involved in scale up of selected interventions ( Phase 1) and Phase 4 generating cross-case mid-range theories represented in systems models of scaling up validated by member checking. MethodsĪ mixed method study combining a realist perspective and systems analysis (causal loop diagrams) of scaled-up physical activity and/or nutrition interventions implemented at a state/national level in Australia (2010–18). This paper aims to understand how different contexts of scaling up interventions affect mechanisms to produce intended and unintended scale up outcomes. Sustainable shifts in population behaviours require system-level implementation and embeddedness of large-scale health interventions.
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