BMC Public Health

BackgroundDuring the COVID-19 pandemic, public health departments have issued guidelines to limit viral transmission. In this environment, people will feel urges to engage in activities that violate these guidelines, but research on guideline adherence has been reliant on surveys asking people to self-report their typical behaviour, which may fail to capture these urges as they unfold. Guideline adherence could be improved through behaviour change interventions, but considering the wide range of behaviours that COVID-19 guidelines prescribe, there are few methods that allow observing changes of aggregate guideline adherence in the wild. MethodsIn order to administer interventions and to obtain contemporaneous data on a wide range of behaviours, we use ecological momentary assessment. In this preregistered parallel randomised trial, 95 participants aged 18-65 from the UK were assigned to three conditions using blinded block randomisation, and engage in episodic future thinking (n = 33), compassion exercises (n = 31), or a sham procedure (n = 31) and report regularly on the intensity of their occurrent urges (min. 1, max. 10) and their ability to control them. We investigate whether state impulsivity and vaccine attitudes predict guideline adherence, while assessing through which mechanism these predictors affect behaviour. FindingsWe found that episodic future thinking (b = -1.60) and compassion exercises (b = -1.40) reduce the intensity of urges. State impulsivity is associated with stronger urges, but we found no evidence that vaccine hesitancy predicts lesser self-control. InterpretationWe conclude that episodic future thinking exercises and compassion training may be used to stimulate compliance of individuals who are a risk for the community, such as those in voluntary self-isolation.

Optimising preconception health in women and men holds significant potential for improving pregnancy and offspring health outcomes. To create a picture of the state of preconception health in the UK, this study aimed to describe the prevalence of and changes in preconception health indicators reported in three British birth cohort studies: the 1970 British Birth Cohort Study (BCS70; born in 1970; N=17,198), Next Steps (1989-1990; N=15,770), and Millennium Cohort Study (MCS; 2000-2002; N=19,517). The analysis focused on data obtained during participants adolescence (16-17 years) and subsequent follow-ups at 25-26 years for BCS70 and Next Steps. Self-reported preconception indicators were defined in line with a previously published review and reported as proportions. Across cohorts, data were available for 14 preconception indicators across four domains: health behaviours and weight, reproductive health and family planning, physical health conditions, and wider determinants of health. Findings revealed persistent suboptimal health behaviours in both genders and across generations, including low intakes of fruit. While alcohol, tobacco, and soft drink intake decreased across generations, obesity prevalence surged. This study underscores the need for public health interventions targeting the root causes of adverse health behaviours towards improvement of fruit consumption, further reduction in alcohol, tobacco, and soft drink consumption, and addressing the escalating obesity rates among individuals of reproductive age. Ongoing monitoring is needed to continue tracking these existing indicators over time, while improved data quality and availability of a wider range of preconception indicators are crucial to comprehensively understanding the complexities of preconception health, enabling the development of more targeted and effective interventions.

During adolescence, many young people start to make more independent food purchases. Subsequently, these independent food choices will increasingly contribute to their overall diet quality; little is known, however, about this relationship. This study aimed to examine the role adolescents independent food purchases play in their diet quality and assess if these relationships vary according to socio-economic status. A convenience sample of adolescents aged 11-18 years and attending secondary school or college in Hampshire, England, were recruited to participate in a one-week cross-sectional observational study. A validated 20-item Food Frequency Questionnaire assessed diet quality. Participants used an ecological momentary assessment mobile phone app to record food purchases. Over seven days, 552 food/drink items were purchased on 253 food purchasing occasions by 80 participants. The majority of purchases (n=329, 60%) were coded as not adhering to the UK Eatwell Guide, 32% were coded as adhering and 9% fell between these two categories. Healthier food purchasing was associated with better diet quality ({beta} 0.48, (95%CI 0.01, 0.96) p=0.05); results attenuated after adjustment for confounders ({beta} 0.36, (95%CI -0.15, 0.87) p=0.16). Interaction models showed purchasing healthfulness was more strongly associated with diet quality among young people of lower SES (p=0.01). The majority of adolescents independent food purchases did not adhere to healthy eating guidelines. For adolescents experiencing socioeconomic disadvantage, these food choices had a more detrimental impact on their overall diet quality than they did for more advantaged adolescents. Future research should focus on identifying ways to support more healthful independent food choices by adolescents to reduce dietary inequalities and improve health and well-being among the next generation of adults.

In the US, public health officials discouraged travel and social gatherings for Thanksgiving. Data suggests that many individuals did travel over the holidays, albeit in smaller numbers than previous years. Using an online panel survey of individuals across ten US states, we found that many individuals reported spending Thanksgiving outside of their home (25.9%) or at home with at least one non-household member (27.3%). Among those who were tested, those who had Thanksgiving outside their home were significantly more likely to self-report a positive PCR test for SARS-CoV-2 infection in the prior two weeks compared to those who had Thanksgiving at home with non-household members or with household members only (41.7% vs. 21.4% and 13.8%, respectively; p<0.001). Persons who had Thanksgiving outside their home and tested positive for SARS-CoV-2 participated in a median 35 (IQR: 21 - 53). non-essential activities compared to those who had Thanksgiving at home and tested positive (median 3 activities, IQR 0-13). Notably, planned travel over the December holidays was most common among those who tested positive for SARS-CoV-2 in the prior 2 weeks (66.5%) compared with 25.4% of those who tested negative in the prior 2 weeks and 11.0% among those who were not tested. While public health authorities should continue promoting messages to dissuade travel and social gatherings over the holidays, as supported by these data, it is equally important to promote messaging on how to get together in a "low-risk" manner for those who travel and plan gatherings. In particular, it is critical that those who do travel or visit with others outside their household do so cautiously and avoid or significantly minimize all other activities where they may potentially acquire and transmit infection in the weeks prior to and after their visit.

IntroductionSchools are recommended settings for promotion of healthy eating, but to achieve their intended impact, initiatives must be implemented population wide. There is currently limited data available to assess the implementation of Australian school-based healthy eating initiatives. ObjectiveTo assess the implementation of healthy eating initiatives in Australian primary schools and whether implementation is associated with school characteristics. MethodsA cross-sectional study of a nationally representative sample of Australian primary school principals from August 2022 to October 2023. Principals reported on implementation of 32 healthy eating initiatives grouped by guideline-informed opportunities: healthy food in the classroom, at school, brought to school, and outside of school. Prevalence estimates were weighted using iterative ranking to reflect population characteristics. Logistic regression models assessed the associations between initiatives and school characteristics. ResultsPrincipals or their representatives from 569 Australian schools completed the survey. Prevalence of initiative implementation varied considerably, ranging from 7% to 97%. The least and most frequently implemented initiative in the classroom was Teachers acted as healthy eating role models for students and Students supported to be healthy eating role models for peers (both 8%) and Permission or breaks to drink water in class time in [&ge;]80% of classes daily (97%); to increase healthy food at school was Provide incentives or rewards to children for purchasing/choosing healthy foods or drinks at school (11%) and Install water stations for free access to cooled plain or optionally carbonated water (64%); to improve healthy food brought to school was Workshops with parents on healthy eating (14%) and Information on healthy eating sent home to parents (88%); and to improve healthy eating outside of school was Promote healthy food options at shops close to school and Community members acted as healthy eating role models for students (both 15%) and Healthy eating programs delivered in partnership with community organisations or services (31%). A range of initiatives were associated with school size (5 initiatives) including Provide free fruits and vegetables to children and Provide free healthy school lunches; geographic remoteness (7 initiatives) such as Teachers acted as healthy eating role models for students and Implement healthy cooking programs or similar healthy eating experiences, or socio-economic status of school locality (3 initiatives) such as Implement healthy fundraising policies and Provide free breakfast to children. ConclusionThis first national study to comprehensively assess the implementation levels of a broad range of healthy eating initiatives reveals key insights into where policy and practice support is needed. Implementation of the initiatives varied significantly, with some associations with school characteristics. Initiatives with low implementation identifies opportunities for further investigation.

BackgroundDuring Fall 2020 in the United States (U.S.), despite high COVID-19 case numbers and recommendations from public health officials not to travel and gather with individuals outside ones household, millions of people gathered for Thanksgiving. The objective of this study was to understand if individuals behaviors and risk perceptions influenced their decision to gather, and if they did gather, their subsequent test seeking and diagnoses. MethodsParticipants were part of the CHASING COVID Cohort study - a U.S. national prospective cohort. The study sample consisted of participants who completed routine questionnaires before and after Thanksgiving. Non-pharmaceutical interventions (NPIs) use informed behavioral risk scores and a score of perceived risk of COVID-19 were assigned to each participant. Multinomial logistic regression models were used to assess the association between higher risk behaviors and gathering with other households, and the association of gathering with subsequent testing and test positivity. ResultsA total of 1,932 (40.5%) cohort participants spent Thanksgiving with individuals from at least one other household. Participants with higher behavioral risk scores had greater odds of gathering with one other household (aOR: 2.35, 95% CI: 2.0, 2.7), two other households (aOR: 4.54, 95% CI: 3.7, 5.6), and three or more other households (aOR: 5.44, 95% CI: 4.1, 7.2). Participants perceiving COVID-19 as a low-risk to themselves and others had greater odds of gathering with one other household (aOR: 1.12, 95% CI: 0.97, 1.3), two other households (aOR: 1.39, 95% CI: 1.1, 1.7), and three or more other households (aOR: 1.86, 95% CI: 1.4, 2.4). Those who spent Thanksgiving with one or more other households had 1.23 times greater odds (95% CI: 1.1, 1.4) of having a COVID-19 test afterward. There was no association between gathering for Thanksgiving and subsequent COVID-19 test positivity or developing COVID-19 symptoms. ConclusionsThose who gathered with other households for Thanksgiving tended to engage in higher-risk activities. Thanksgiving gathering with other households was not associated with subsequently testing positive for COVID-19, but only a small proportion obtained post-travel testing. Public health messaging should emphasize behavior change strategies that promote safer gathering.

COVID-19 risk mitigation behavior, including social distancing and mask wearing, was a principal factor influencing the spread of COVID-19. Yet this behavior, and its association with COVID-19 perceptions and beliefs, is poorly understood. Here we used a mixed methods approach combining serious game data with survey instruments to describe relationships between perceptions and behavior. Using a series of survey questions, participants were described along a spectrum denoting their perception of their susceptibility to COVID-19 associated with a list of activities. Afterwards, participants engaged with a serious game to examine behavioral responses to scenarios involving shopping at a grocery store and going to a park during simulated pandemic conditions. Messages describing the simulated infection risk were shown to drive many behavioral decisions. Another significant correlate, derived from survey results, was the participants perception of susceptibility associated with various activities for acquiring the COVID-19 infection. Individuals that perceived every day activities, such as grocery shopping, as unlikely to lead to a COVID-19 infection spent more time near others in the game-simulated grocery store environment compared to those that consider such activities as risky. Additionally, we found that participant behavior became increasingly risky as time progresses if they were lucky enough not to experience an infection. This reflects behavior observed in the United States and more broadly, possibly explains how people update their perception of the risk of activities. Overall, results show a link between perception and action with regards to COVID-19 and support the use of targeted risk messaging to influence behavior. Moreover, the link between reported real-world perceptions and game behavior suggest that serious games can be used as valuable tools to test policies, risk messaging and communication, with the goal of nudging individuals with varied and nuanced perceptions and belief sets towards behaviors that will reduce the impact of COVID-19.

BackgroundKnowledge of the distribution, prevalence, and clustering of multiple health and lifestyle related behaviours (HLBs) among adolescents can inform the development of more effective health-promoting policies and interventions. We therefore assessed the clustering of multiple HLBs among 11, 13 and 15-year-old Swedish adolescents and examined the socioeconomic and demographic correlates of each cluster. MethodsWe used data from the 2017/2018 Swedish Health Behaviour in School-aged Children (HBSC) study to conduct sex and age-stratified latent class analysis (LCA). The LCA was based on five HLBs: eating behaviour and habits (EBH), physical activity (PA), tobacco usage (TU), alcohol consumption (AC) and sleeping habits and patterns (SHPs). Multinomial logistic regression models were used to assess the associations between the identified clusters and the socioeconomic and demographic characteristics of adolescents and their parents. ResultsHealth behaviours varied by age and sex. Four distinct clusters were identified based on sex: cluster 1 (Mixed eating behaviours and habits, physical activity and low alcohol consumption), cluster 2 Healthy lifestyle behaviours), cluster 3 (Unhealthy lifestyle behaviours), and cluster 4 (Breakfast, low alcohol consumption and tobacco usage). In the age-stratified analyses, three clusters were identified: cluster 1 (Unhealthy lifestyle behaviours), cluster 2 (Moderately healthy lifestyle behaviours) and cluster 3 (Healthy lifestyle behaviours). The multinomial analysis showed that sex, age, family situation and perceived family wealth were strong predictors of health behaviours. In particular, unhealthy behaviours showed the most frequent associations with socioeconomic disadvantage, having a migrant background and living in reconstructed families or single parent households. ConclusionsHealth behaviours vary significantly based on socioeconomic and demographic factors. Targeted policy and interventions programmes can effectively improve HLBs among vulnerable and at-risk adolescents.

BackgroundLocal authorities (LAs) in England are increasingly using the planning system to control the proliferation of hot food takeaway outlets ( takeaways) near schools as part of a range of policies to promote healthy weight in children. These takeaway management zones (TMZs) include restrictions on planning permission to open new takeaways within a certain distance of a school. In this qualitative study we explore young peoples perspectives of TMZs. MethodsWe purposively recruited 46 young people (aged 11-18 years old) attending secondary school across two contrasting London LAs with operating TMZs. We conducted semi-structured, walking group interviews ("go-alongs") in January-February 2023 in the local food environment close to participants schools. We analysed data using framework analysis. ResultsParticipants generally viewed TMZs as reasonable and uncontroversial but were not always aware that TMZs were in operation. Although participants understood that TMZs prevented new outlets from opening, they observed they did not seem to reduce existing provision. This was viewed positively as it did not result in the closure of local takeaways perceived as important components of the social fabric of school life. Participants believed that the potential health impact of TMZs is limited by their exclusive focus on takeaways as other food retail commonly patronised by young people, such as convenience stores, are important sources of unhealthy food. Participants also identified inadequacies in the wider food environment, including the school dining environment and access to food delivery apps. ConclusionsOur findings suggest that although young people find TMZs acceptable and believe they have some positive impact on diet, they did not perceive TMZs as effective as they could be. Participants articulated that the management of takeaways on their own is unlikely to reduce exposure to unhealthy foods. Widening the remit of planning policy to include outlets selling convenience foods may be important for policy optimisation. HighlightsO_LIYoung peoples perspectives of takeaway management zones are explored C_LIO_LIAcceptability of zones was high as the existing food environment remains unchanged C_LIO_LIThe impact of takeaway management zones was deemed limited by its focus and scope C_LIO_LIConsidering wider aspects of the food environment is key for policy development C_LIO_LIFuture policy should also consider young peoples social and emotional needs C_LI

BackgroundThere is accumulating evidence that ultra-processed foods are associated with many non-communicable diseases. In the United Kingdom, ultra-processed foods account for more than half of mean daily energy intake. There is limited evidence describing how individuals make sense of ultra-processed foods in their daily lives. We aimed to explore: public perceptions of ultra-processed foods and their relationship to health; how these are shaped by different information sources; whether perceptions influence purchasing and consumption; and proposed solutions for reducing ultra-processed food consumption. MethodsWe undertook 30 qualitative, one-to-one interviews with people living in the UK, aged 18 years or older, with household responsibility for food activities recruited using social media advertisements. Interviews followed a semi-structured topic guide reflecting the aims. Data were analysed using reflexive thematic analysis. Members of a Public Involvement and Engagement group helped interpret emergent findings. ResultsFood processing often made more sense to participants as a continuum rather than ordinal categories. There was particular confusion regarding the boundary between processed and ultra-processed food. Participants described an overwhelming food-related information environment. Personal and anecdotal experience was particularly powerful. While industry-sponsored information was met with scepticism, the personal testimonies of social media influencers were seen as relatable or helpful. Participants perceptions of ultra-processed foods sometimes influenced their purchasing and consumption. However, cost, convenience, taste and family practices were often as or more important. Approaches to help reduce UPF consumption ranged from education to fiscal policies. ConclusionsThese findings suggest that the public need help navigating the complex food information landscape and not just with filling specific knowledge gaps around ultra-processed foods and other food-related topics. Policy approaches should combine improved public communication with upstream interventions that modify the food environment to make choosing less processed foods easier and more appealing.

Research on under-vaccination often segments populations using demographic or administrative variables that are operationally useful but fail to capture identity dimensions relevant to vaccination decisions. Drawing on social identity theory, we propose an identity-landscape approach distinguishing identity membership, identity centrality, and multidimensional identity structure. Using a cross-sectional survey of 1,000 UK parents, we measured 65 identity indicators, identity-importance ratings, and their association with attitudinal and behavioural hesitancy toward childhood vaccination using validated scales. Beyond established socio-demographic predictors, alternative-medicine and natural-lifestyle identities, as well as affiliation with social media networks, were linked to greater hesitancy. Greater centrality of religion and political affiliation within personal identity was also associated with higher hesitancy. Principal component analysis suggested that individuals actively engaged across multiple societal issues were more hesitant, whereas stereotypically male-gendered engagement was associated with lower hesitancy. An identity-focused population segmentation may identify previously unrecognized undervaccinated groups and inform innovative tailored immunization campaigns.

The COVID-19 pandemic is both a global health crisis, and a civic emergency for national governments, including the UK. As countries across the world loosen their lockdown restrictions, the assumption is generally made that the risk of COVID-19 transmission is lower outdoors, and this assumption has shaped decisions about what activities can recommence, the circumstances in which they should re-commence, and the conditions under which they should re-commence. This is important for events and activities that generate outdoor gatherings of people, including both participatory and spectator sport events, protests, concerts, carnivals, festivals, and other celebrations. The review, which was designed to be undertaken rapidly in 15 days, returned 14 sources of evidence of outdoor transmission of COVID-19, and a further 21 sources that were used to set the context and understand the caveats that should be considered in interpreting the review findings. The review found very few examples of outdoor transmission of COVID-19 in everyday life among c. 25,000 cases considered, suggesting a very low risk. However risk of outdoor transmission increases when the natural social distancing of everyday life is breached, and gathering density, circulation and size increases, particularly for an extended duration. There was also evidence that weather had a behavioural effect on transmission, with temperatures that encourage outdoor activity associated with lower COVID-19 transmission. Due to lack of surveillance and tracing systems, and confounding factors and variables, there was no evidence that robustly tested transmission at outdoor mass gatherings (circa 10,000+ people), which are as likely to generate transmission from the activities they prompt (e.g. communal travel and congregation in bars) as from outdoor transmission at the gathering itself. The goal of hosts and organisers of events and activities that generate outdoor gatherings of people is to prevent the escalation of risk from sporadic transmission to the risk of transmission through a cluster outbreak. Considerations for such hosts and organisers include: (1) does the gathering prompt other behaviours that might increase transmission risk?; (2) for each part of the event or activity, how dense is the gathering, how much do people circulate, how large is the gathering, and how long are people there?; (3) is rapid contact tracing possible in the event of an outbreak? These considerations should take place relevant to the size of the underlying risk, which includes the rate of infection in the community and the likely attendance of vulnerable groups. Risk must be balanced and mitigated across the risk factors of density, circulation, size and duration. No one risk factor presents an inherently larger risk than any other, but neither is any one risk factor a magic bullet to eliminate risk. Finally, it is clear that the largest risks from gatherings come from spontaneous or informal unregulated and unmitigated events or activities which do not consider any of the issues, risks and risk factors outlined in this paper

BackgroundSmoking, unhealthy nutrition, alcohol consumption, and physical inactivity (SNAP behaviours) are major risk factors for multimorbidity but are often studied in isolation. Using longitudinal data, Suhag et al. identified clusters of older adults (aged [&ge;]50) with common SNAP behaviour patterns and distinct sociodemographic profiles and multimorbidity prevalence; whether and how these patterns generalise across adulthood remains unclear. AimTo conceptually replicate Suhag et al. across a wider age range using an independent panel study. MethodsWe used data from Waves 7-13 of the UK Household Longitudinal Study, analysing adults (aged [&ge;]16) participating across all seven waves (n=18,008). Repeated-measures latent class analysis identified clusters of adults with common SNAP behaviours at Waves 7, 9, 11 and 13. Multinomial and binomial logistic regression examined how clusters were associated with sociodemographic characteristics and disease status (six disease groups plus multimorbidity), respectively. FindingsSeven clusters were identified: Overall Low-risk (20% of the sample), Insufficiently active (18%), Poor diet and Insufficiently active (23%), Hazardous and Harmful drinkers (11%), Hazardous drinkers, Insufficiently active and Poor diet (14%), Smokers and Drinkers (5%), and Smokers (9%). Behavioural profiles within clusters were largely stable over time. Associations between clusters and disease outcomes were counterintuitive. The cluster labelled Overall Low-risk on the basis of SNAP behaviours had the highest prevalence of multimorbidity, whereas the Hazardous drinkers, Insufficiently active and Poor diet cluster showed lower prevalence across most conditions. These clusters also differed in sociodemographic composition: the Overall Low-risk cluster comprised mainly older women with lower education and income, while the Hazardous drinkers, Insufficiently active and Poor diet cluster was more likely to comprise individuals in the highest education and income groups. ConclusionCluster-analytic techniques can be used to identify population subgroups with distinct behavioural and disease profiles, underscoring the need to consider risk behaviours in conjunction with sociodemographic context.

BackgroundDigital services for sexually transmitted and blood borne infection (STBBI) testing may influence demand in publicly funded health systems by enabling low barrier, self-directed access to testing, raising concerns about repeated use and sustainability. We examined longitudinal utilization of GetCheckedOnline, British Columbias digital STBBI testing service, to characterize testing trajectories and assess factors associated with higher intensity use. MethodsWe conducted a retrospective cohort study using GetCheckedOnline program data for users who created an account between April 2020 and November 2022, with 24 months of follow-up. We used group-based trajectory modelling to identify patterns of testing over time among (1) all users and (2) users with at least one test. Multilevel regression models with local health area random intercepts were used to examine associations between higher intensity trajectory membership, individual risk indicators, and geographic clustering. ResultsAmong 34,228 users, 22,542 (65.9%) completed at least one test and 42,451 tests were conducted (median 1; range 0-44). Two trajectories were identified in both analytic samples, with a minority demonstrating sustained higher intensity testing. The top 10% of users accounted for 39.6% of tests. Higher intensity trajectory membership was associated with sexual risk indicators including having multiple partners, condomless sex with multiple partners, and prior STBBI diagnosis. Geographic clustering across local health areas was modest in the null model (ICC 0.042) and attenuated with adjustment. ConclusionGetCheckedOnline utilization reflects a prevention-oriented pattern that appears more consistent with service needs than indiscriminate overuse. A small subset of users with elevated sexual risk account for higher-intensity testing. Findings support risk aligned stewardship including education and differentiated guidance, rather than universal restrictions to reducing testing volumes. Author SummaryDigital services are being used to make testing for sexually transmitted and blood borne infections (STBBIs) easier to access. Some health systems decision makers worry that online testing could lead to too much testing and higher costs. We examined how people used GetCheckedOnline, British Columbias public online STBBI testing service, over two years. Most people used the service only once or tested occasionally (less than once in six months). A smaller group tested more often. People who tested more often were also more likely to report higher sexual health risk, such as having multiple partners or a recent STBBI diagnosis. This suggests that repeat testing is often done by people who may benefit from testing more often, rather than people testing without need. For health systems, this means it may be more helpful to give clear guidance and education about when to test instead of placing broad limits on access to online testing.

Obesity is a global health challenge associated with increased risk of co-morbidity and mortality. Existing government policies have failed to adequately address obesity. Mapping obesity policy actions (including prevention initiatives and weight-management services (WMS)) using behavioural science can offer insights into how approaches to prevention/management could be improved. This research aimed to identify strengths and gaps in adult obesity policy actions/WMS in Northern Ireland (NI) by conducting a systematic scoping review of grey literature. Obesity policy actions/WMS were mapped out and coded using the Behaviour Change Wheel (BCW), then assessed against obesity risk factors identified from the Foresight Obesity System Map. The breadth of obesity policy actions/WMS was mapped using Google Advanced Searches, grey literature database searches, targeted website searches and stakeholder consultations. Policy actions/WMS were categorised using the UK weight-management tiered system. Policy actions/WMS were coded by BCW intervention type. Foresight variables were coded according to the Capability-Opportunity-Motivation-Behaviour (COM-B) Model. Policy actions/WMS were subsequently mapped against Foresight variables and displayed using a heat map. Twelve Google Advanced Searches, three database searches, n=17 targeted website searches and three stakeholder interviews were conducted (and updated in 2024) identifying a wide range of relevant records (N=127). Results included policies/strategies/guidelines/campaigns/services targeting weight management/obesity. Of the identified policy actions/WMS, 72% were classified as tier 1 (health promotion); 21% tier 2 (community-based weight management programmes); 2% tier 3 (specialist obesity services), 5% were tier 2/3 services and 0% were tier 4 services (metabolic surgery). Education and persuasion were the most commonly coded intervention types from the BCW, followed by enablement and training. Environmental restructuring was limited, as was modelling and incentivisation approaches. Behavioural mapping of obesity policy actions/WMS is a novel approach with the potential to influence policy/service development. In NI, using this method illustrated policy gaps and significant opportunities to improve WMS provision.

Energy market turmoil due to the Russian-Ukrainian war increased global fuel/food prices. While risks to energy and food security have been suggested, little research has documented impacts for the most vulnerable. During September-October 2022, surveys were administered to 701 households using pay-as-you-go liquefied petroleum gas (PAYG LPG) for clean cooking in an informal settlement in Nairobi, Kenya. Paired t-tests compared PAYG LPG consumption/payment behaviors before (July-October 2021) and during a >15% inflationary food price period (July-October 2022). Three-quarters (74%; %; n=520) of all households and 94% of food insecure households (n=393; 54% of sample) changed their dietary behavior (changed foods cooked, skipped more meals, and/or reduced PAYG LPG consumption) in 2022. Between July-October 2021 and 2022, PAYG LPG prices increased by 16% (214 Kenyan Shilling (KSh)/kg ($1.53USD/kg) to 249 KSh/kg ($1.78USD/kg) and households reduced their monthly PAYG LPG expenditure by 79% (856 KSh ($6.07USD) to 184 KSh ($1.31USD)). Although 97% of participants continued using PAYG LPG in July-October 2022, average consumption declined by two-thirds (0.82 to 0.27 kg/capita/month; difference(paired-t):-0.28 95%CI:[-0.36,-0.21]). Higher food and LPG prices in 2022 led to substantial declines in food security and LPG consumption in an informal urban settlement, highlighting increased obstacles to achieving the Sustainable Development Goals. HighlightsO_LI67% reduction (0.82 to 0.27 kg/capita/month) in mean PAYG LPG use between 2021 and 2022 C_LIO_LI97% of homes continued using LPG but monthly fuel expenditure decreased 79% between 2021- 2022 C_LIO_LI56% of households were food insecure C_LIO_LI94% of food insecure homes changed foods cooked, skipped meals or reduced LPG use in 2022 C_LIO_LIOne of first studies linking rising food prices with declines in clean energy consumption C_LI SynopsisUsing smart meter data, this study illustrates that LPG consumption for cooking dropped by two-thirds and food insecurity increased in an informal urban settlement due to higher food costs in 2022.

IntroductionThis study evaluates the effects of a three-year conditional cash transfer program on educational outcomes and child marriage among Lebanese, Syrian and Palestinian adolescent girls in Lebanon. MethodsIn the third year of the program, survey data were collected from households receiving a cash transfer conditional on adolescent girls school attendance and a comparison group of households. We conducted descriptive analysis and logistic regression models comparing outcomes, at endline, between girls in the intervention and comparison groups. Survey data on marriage and school dropout were also collected from all households of girls who were ever enrolled in the intervention or comparison groups over the three years of the program. Survival analysis was used to compare the transition to marriage and school dropout among girls who received cash transfers for different durations. ResultsAmong year three participants, receiving cash transfers was associated with improved educational and attitudinal outcomes, but not reductions in early marriage. Comparing all program participants, receipt of two or more years of cash transfers was associated with significant reductions in the risk of early marriage but receipt of cash for one year only was not. Each additional year of cash receipt was associated with reductions in the risk of school dropout. ConclusionOur findings point to the promise of cash for education as an approach to improving school retention and reducing early marriage among adolescent girls in humanitarian settings, provided that cash transfers can be implemented for a sufficient duration of time. Implications and contributionsThis is one of the first studies to evaluate the impacts of a CCT program on early marriage in a humanitarian setting. Leveraging longitudinal data, our findings provide evidence on the promise of cash conditional on schooling to improve school retention and reduce early marriage among conflict-affected adolescent girls.

ObjectiveTo assess perspectives of online grocery shopping during the COVID-19 pandemic among youth, rural residents, and Supplemental Nutrition Assistance Program (SNAP) participants. DesignOpen-ended text message survey data. Survey questions assessed rates of use and perspectives of online grocery shopping among youth and their families during the COVID-19 pandemic. Qualitative analysis of survey data from 875 participants (response rate=76.4%) to identify themes in experience with multivariable logistic regression to test associations between online grocery shopping (pickup, delivery, or either) with rurality and SNAP participation. SettingUnited States ParticipantsNationwide text-messaging poll of youth (14-24 years-old) recruited to meet benchmarks based on the American Community Survey. ResultsDuring the pandemic online grocery shopping was used frequently (46.7%). Safety and convenience were the primary reasons for preferring a shopping mode (in-person or online). Most online shoppers had positive experiences (59.4%), primarily due to convenience; negative experiences (28.3%) were from inaccuracies, inconveniences of the process, and delivery costs. Rural and suburban residence was associated with higher pickup (OR 2.02 and 1.51, respectively, p=.03) and lower delivery use (OR 0.33 and 0.72, respectively, p=.003) compared to urban residence. SNAP participation was not associated with any type of online grocery shopping. ConclusionsOnline grocery shopping is common among youth and their families regardless of rurality or SNAP participation, but there are several youth-identified areas for improvement. GRAPHICAL ABSTRACT O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=98 SRC="FIGDIR/small/22277101v1_ufig1.gif" ALT="Figure 1"> View larger version (28K): org.highwire.dtl.DTLVardef@1deebb7org.highwire.dtl.DTLVardef@456b86org.highwire.dtl.DTLVardef@19656a9org.highwire.dtl.DTLVardef@113a660_HPS_FORMAT_FIGEXP M_FIG C_FIG

ObjectiveKey to slowing the spread of SARS-Cov-2 is adherence to preventive behaviours promoted through government policies, which may be influenced by policy awareness, attitudes and concerns about the virus and its impacts. This study assessed determinants of adherence to major coronavirus preventive behaviours, including demographics, attitudes and concerns, among Canadians during the first pandemic wave. MethodsAs part of the iCARE study (www.iCAREstudy.com), we weighted data from two population-based, online surveys (April and June, 2020) of Canadian adults. Questions tapped into behaviour change constructs. Multivariate regression models identified determinants of adherence. ResultsData from 6,008 respondents (51% female) were weighted for age, sex, and province. Awareness of government policies was high at both time points (80-99%), and adherence to prevention behaviours was high in April (87.5%-93.5%) but decreased over time, particularly for avoiding social gatherings (68.1%). Adherence was worse among men, those aged 25 and under, and those currently working. Aligned with the Health Beliefs Model, perceptions of the importance of prevention behaviours and the nature of peoples COVID-19-related concerns were highly predictive of adherence. Interestingly, health and social/economic concerns predicted better adherence, but having greater personal financial concerns predicted worse adherence at both time points. ConclusionAdherence to COVID-19 prevention behaviours was worse among men, younger adults, and workers, and deteriorated over time. Perceived importance of prevention behaviours measures and health and social/economic concerns predicted better adherence, but personal financial concerns predicted worse adherence. Results have implications for tailoring policy and communication strategies during subsequent pandemic waves.

BackgroundOut-of-home eating makes a significant contribution to dietary intake. Food consumed out- of-home is often higher in energy and less nutritious than food consumed at home. Evaluating the healthiness of catering practices in the out-of-home food sector (OHFS) is challenging for small-to-medium sized businesses, and validated assessment tools are limited. The objective of the present research was to develop and validate a menu healthiness assessment tool for small-to-medium sized UK OHFS businesses. MethodsWe devised and validated a menu healthiness assessment tool, Menu-Health, based on UK nutritional guidance and recommendations. Content validity was assessed by six independent experts. Inter-rater reliability and predictive validity were assessed by applying the tool to 66 OHFS businesses in the Northwest of England. We sampled 33 businesses with an accredited tiered local authority healthier catering award. These businesses were paired with similar non-award holder businesses, matched by business type, cuisine type and Indices of Multiple Deprivation (IMD) decile. ResultsInter-rater agreement for overall menu healthiness assessment score was 92%. The tool also had strong inter-rater agreement and excellent inter-rater reliability. Only 18% of assessed OHFS businesses had a good overall healthiness score ([&ge;]71%). Regression analyses examined if award status or award level, business type and IMD decile predicted healthiness scores. As expected, takeaways and dessert outlets had lower healthiness scores than cafes, restaurants and pubs, as did outlets located in more deprived areas (IMD 1-2 vs. 3-10). Award holder status was not significantly associated with healthiness scores. However, higher award tier level was associated with higher menu healthiness scores. ConclusionMenu-Health provides a comprehensive, validated and reliable method of assessing and comparing the food, drink and catering practices of small-to-medium sized UK OHFS businesses. It is potentially a useful tool for researchers, public health teams and local authorities to evaluate the healthiness of local OHFS environments.