Icing or cake? Grant competitions as a model for funding chronic disease prevention in Tasmania, Australia.

Competitive grant funding is a well-established mechanism for generating activity and interventions in the field of chronic disease prevention. Yet grant competitions may be burdensome for organizations, and money may not be enough to bring about lasting change in communities. In this study, we explore the dynamics of awarding and receiving money in the context of a state-level government grant competition to support community organizations and promote community-driven action for health and well-being in Tasmania, Australia. Drawing on reflections of successful grant recipients and real-time observation of grant decision-making, we consider the role and value of grant competitions both for individual organizations and for generating broader change processes. We found that grant competitions operated according to an 'icing-on-the-cake' approach to funding, whereby money was provided for extra activities and new initiatives. In this way, the grant competition was valuable not only for stimulating new programme activities but also to effect broader organizational change, such as developing planning capacity, igniting new directions and pushing organizations towards 'health'-focused activities. But for smaller organizations, grant funding was often stretched to support core work (i.e. cake rather than icing). Grants targeting specific focus areas could be a drain on resources if they diverted staff time away from core activities. We suggest an alternative approach to funding in which grants are able to be more responsive to the needs of community organizations and the support they require, as well as to desired outcomes. We describe the policy response to the results to date.

When a person attends a class on buying, storing and cooking fresh vegetables, or enrols in a walking group, or joins others to learn first aid, this 'community-based health promotion' is often the product of ideas and actions taken by staff employed in health services, local government and the community sector (e.g. neighbourhood houses). Grant competitions are intended to foster new ideas by providing money for new services, equipment or expertise. We investigated what happens behind the scenes when state government grants are awarded. We found that large organizations fare well as they can use new funds to innovate or gather evidence about the value of new ventures. But many smaller organizations suffer as they do not have the person power to write grants, hire extra staff or support new activities. Restrictions on what can and can't be done with grant money can make receiving grants a burden, that is, grants fund 'icing' when what is needed is 'cake'. An inadequate mix of funding types at the community level can mean that grant schemes are pressured to fill gaps for which they were not designed. Our policy partners have responded with more community-centred grant making, better tailored to various levels of community organizational need.

Soft infrastructure: the critical community-level resources reportedly needed for program success.

BACKGROUND: The mechanisms typically used to fund health promotion in communities, either as part of an effort to scale-up programs or to support the design of local activities, often pay insufficient attention to the foundational means of enhancing well-being. Only recently have researchers begun to critically 'unpack' how funding processes connect with and activate local community capacities. METHODS: We conducted a thematic analysis of 33 interviews with policy and program administrators in public health and local community workers and volunteers. We invited them to expound on their understandings of resources - specifically, what needs to be in place to make funded programs successful and/or what do communities draw on to make funded programs effective. RESULTS: Policy and program administrators reflected mostly on the importance of traditional resources, such as adequate funding and staffing. Community-based participants often went further to describe psychological and sociological resources - the "soft infrastructure" which included trust and hope. Both groups emphasised the importance of building networks and relationships at multiple levels. Community workers also provided examples of how resources grow and improve in value in combination with other processes or through pathways of resource use or resource distribution. So, resources like information/knowledge are made more valuable when relayed locally. Physical amenities (e.g., meeting spaces, kitchens) have an instrumental role, but also act powerfully as a symbolic resource for identity. Participants reported that funding processes can damage the resources required for community health improvement. Funding instability undermines capacity. The ongoing threat of funding removal was described by one administrator as community "bullying". CONCLUSIONS: Processes of health promotion funding, and even standard processes of program scale-up and readiness assessment, risk underestimating the range of resources that are fundamental for community health improvement, particularly among disadvantaged communities. Funders should design ways to resource communities so that there is constant attention to and coaching of critically important diverse processes of resource growth, independent of program-specific funds.

Scale-up of prevention programmes: sustained state-wide use of programme delivery software is explained by normalised self-organised adoption and non-adoption.

BACKGROUND: Population-level health promotion is often conceived as a tension between "top-down" and "bottom-up" strategy and action. We report behind-the-scenes insights from Australia's largest ever investment in the "top-down" approach, the $45m state-wide scale-up of two childhood obesity programmes. We used Normalisation Process Theory (NPT) as a template to interpret the organisational embedding of the purpose-built software designed to facilitate the initiative. The use of the technology was mandatory for evaluation, i.e. for reporting the proportion of schools and childcare centres which complied with recommended health practices (the implementation targets). Additionally, the software was recommended as a device to guide the implementation process. We set out to study its use in practice. METHODS: Short-term, high-intensity ethnography with all 14 programme delivery teams across New South Wales was conducted, cross-sectionally, 4 years after scale-up began. The four key mechanisms of NPT (coherence/sensemaking, cognitive participation/engagement, collective action and reflexive monitoring) were used to describe the ways the technology had normalised (embedded). RESULTS: Some teams and practitioners embraced how the software offered a way of working systematically with sites to encourage uptake of recommended practices, while others rejected it as a form of "mechanisation". Conscious choices had to be made at an individual and team level about the practice style offered by the technology-thus prompting personal sensemaking, re-organisation of work, awareness of choices by others and reflexivity about professional values. Local organisational arrangements allowed technology users to enter data and assist the work of non-users-collective action that legitimised opposite behaviours. Thus, the technology and the programme delivery style it represented were normalised by pathways of adoption and non-adoption. Normalised use and non-use were accepted and different choices made by local programme managers were respected. State-wide, implementation targets are being reported as met. CONCLUSION: We observed a form of self-organisation where individual practitioners and teams are finding their own place in a new system, consistent with complexity-based understandings of fostering scale-up in health care. Self-organisation could be facilitated with further cross-team interaction to continuously renew and revise sensemaking processes and support diverse adoption choices across different contexts.

Sydney's 'last drinks' laws: A content analysis of news media coverage of views and arguments about a preventive health policy.

INTRODUCTION: News media representation of preventive health policies can influence public discussion and political decision making, impacting policy implementation and sustainability. This study analysed news media coverage of the contested 'last drinks' alcohol laws in Sydney, Australia, to understand the arguments made by different 'actors' (stakeholders) regarding the laws and provide insights on how preventive health policies are positioned within media discourse. METHODS: We identified print and online news media articles discussing the laws from 2014 to 2020. Content analysis was used to quantify the arguments made to justify support or opposition to the laws. RESULTS: A total of 445 articles were included for analysis. Four hundred and thirty-five actors were identified, with industry actors mentioned most (213 times) followed by health actors (136 times). There were more quotes from opponents of the laws compared to supporters of the laws (57% vs. 25%). The proportion of media mentions reduced for supporters (34% in 2014 to 14% in 2020) while mentions increased for opponents (47% in 2014 to 73% in 2020). Supporters used arguments about crime, safety and health. Opponents of the laws focused on issues such as Sydney's 'night time economy' and negative impacts of the laws. DISCUSSION AND CONCLUSIONS: Opponents of the laws strategically used the media to influence public debate. Opponents, including industry actors, also ignored the health impacts of alcohol and utilised campaign groups to advocate against the laws. These findings have implications for how governments and advocates communicate and build support for contested preventive health policies.

Using citizen science to engage the public in monitoring workplace breastfeeding support in Australia.

ISSUE ADDRESSED: Returning to work is a major barrier to continued breastfeeding. While many large organisations in Australia have policies to support breastfeeding and expressing at work, it is not known how these are implemented in practice, what support is available in smaller workplaces or to what extent workplace support meets the needs of breastfeeding mothers. METHODS: This pilot study trialled a citizen science approach where members of the public provided photographs and descriptions of breastfeeding facilities and support within their workplaces. The study was promoted through community networks and social media, and data were submitted via an online survey. Data were analysed inductively to identify key themes. RESULTS: Thirty-seven participants provided data on breastfeeding support in their workplace. Three key themes were identified: physical features and facilities; workplace culture; and organisational and occupational characteristics. There was considerable variation in workplace support and around half of the participants indicated that they had to use communal, poorly equipped and/or unhygienic spaces to breastfeed or express at work. CONCLUSION: While some employers have taken important steps towards supporting mothers to combine breastfeeding and work, there is room for improvement. Through this pilot study, we have demonstrated the feasibility and value of using a citizen science approach to obtain data from a range of workplaces along with perceptions of workplace characteristics that support or hinder breastfeeding and expressing at work. SO WHAT?: Citizen science is a useful approach to capturing data on workplace support for breastfeeding and could be scaled up to enable ongoing monitoring. The findings raise important issues around the interpretation and implementation of current legislation to support mothers in the workplace.

The Weight of Words: Co-Analysis of Thick Ethnographic Description and "Friction" as Methodological Strategies in a Health Policy Research Partnership.

Co-production partnerships between policymakers, practitioners, and researchers are designed to facilitate production of relevant and readily usable research in health policy and practice contexts. We describe methodological strategies for in-depth collaborative analysis based on a co-produced ethnography of health promotion practice, involving ethnographic researchers and government-based research partners. We draw on a co-production dialogue to reflect critically on the role and value of co-analyzing research findings using thick ethnographic descriptions. The ambiguity of ethnographic imagery allowed flexibility in interpretation of findings and also generated friction. Specific ethnographic images became focal points for productive friction that crystallized ethical and analytical imperatives underpinning the diverse expertise in the team. To make the most of co-analysis of thick ethnographic descriptions, we assert that friction points must be reflexively considered as key learning opportunities for (a) higher order analysis informed by diverse analytical perspectives and (b) more cohesive and useful interpretations of research findings.

Core and peripheral organisations in prevention: Insights from social network analysis.

ISSUE: Formal (eg funded) community-level organisational collaborations are becoming more common in prevention. Rapid methods to assess organisational relationships could allow us to consider the significance of any pre-existing relationship patterns in communities that might impact on collaboration effectiveness. Insights may identify new options for practice. METHODS: We used social network analysis to study organisations engaged in prevention but not (yet) part of a formal purposive collaboration. Within a single community, we identified organisations providing programs in chronic disease prevention. We used whole network analysis methods to describe the extent to which organisations were aware, had contact, coordinated activity and/or collaborated more intensively. We also identified the contribution made to prevention locally. Results were compared with key informant interviews. RESULTS: There was an identifiable network structure, with more relationships across the network than one would expect by chance. The network had a core-periphery structure, meaning that, in terms of the relationships we measured, there were highly connected organisations who were strongly interlinked with each other (the core), alongside less connected organisations that were linked to the core but not to each other (the periphery). Core organisations were significantly more likely to have expertise in prevention and to have prevention staff. CONCLUSIONS: To our knowledge, it is new to identify inherent or "pre-existing" core-periphery structures in interorganisational health promotion. Yet, core-periphery structures are common in many social settings. They advantage entities in the core and are prone to further entrenchment. SO WHAT?: Our results map and quantify intuitive understandings about organisational "key players", thus enabling practitioners/organisations to critically reflect on what their role should be when it comes to activating communities ie to embed, or attempt to counterbalance, pre-existing power structures.

Applying systems thinking to knowledge mobilisation in public health.

CONTEXT: Knowledge mobilisation (KM) is a vital strategy in efforts to improve public health policy and practice. Linear models describing knowledge transfer and translation have moved towards multi-directional and complexity-attuned approaches where knowledge is produced and becomes meaningful through social processes. There are calls for systems approaches to KM but little guidance on how this can be operationalised. This paper describes the contribution that systems thinking can make to KM and provides guidance about how to put it into action. METHODS: We apply a model of systems thinking (which focuses on leveraging change in complex systems) to eight KM practices empirically identified by others. We describe how these models interact and draw out some key learnings for applying systems thinking practically to KM in public health policy and practice. Examples of empirical studies, tools and targeted strategies are provided. FINDINGS: Systems thinking can enhance and fundamentally transform KM. It upholds a pluralistic view of knowledge as informed by multiple parts of the system and reconstituted through use. Mobilisation is conceived as a situated, non-prescriptive and potentially destabilising practice, no longer conceptualised as a discrete piece of work within wider efforts to strengthen public health but as integral to and in continual dialogue with those efforts. A systems approach to KM relies on contextual understanding, collaborative practices, addressing power imbalances and adaptive learning that responds to changing interactions between mobilisation activities and context. CONCLUSION: Systems thinking offers valuable perspectives, tools and strategies to better understand complex problems in their settings and for strengthening KM practice. We make four suggestions for further developing empirical evidence and debate about how systems thinking can enhance our capacity to mobilise knowledge for solving complex problems - (1) be specific about what is meant by 'systems thinking', (2) describe counterfactual KM scenarios so the added value of systems thinking is clearer, (3) widen conceptualisations of impact when evaluating KM, and (4) use methods that can track how and where knowledge is mobilised in complex systems.

Can an electronic monitoring system capture implementation of health promotion programs? A focussed ethnographic exploration of the story behind program monitoring data.

BACKGROUND: There is a pressing need for policy makers to demonstrate progress made on investments in prevention, but few examples of monitoring systems capable of tracking population-level prevention policies and programs and their implementation. In New South Wales, Australia, the scale up of childhood obesity prevention programs to over 6000 childcare centres and primary schools is monitored via an electronic monitoring system, "PHIMS". METHODS: Via a focussed ethnography with all 14 health promotion implementation teams in the state, we set out to explore what aspects of program implementation are captured via PHIMS, what aspects are not, and the implications for future IT implementation monitoring systems as a result. RESULTS: Practitioners perform a range of activities in the context of delivering obesity prevention programs, but only specific activities are captured via PHIMS. PHIMS thereby defines and standardises certain activities, while non-captured activities can be considered as "extra" work by practitioners. The achievement of implementation targets is influenced by multi-level contextual factors, with only some of the factors accounted for in PHIMS. This evidences incongruencies between work done, recorded and, therefore, recognised. CONCLUSIONS: While monitoring systems cannot and should not capture every aspect of implementation, better accounting for aspects of context and "extra" work involved in program implementation could help illuminate why implementation succeeds or fails. Failure to do so may result in policy makers drawing false conclusions about what is required to achieve implementation targets. Practitioners, as experts of context, are well placed to assist policy makers to develop accurate and meaningful implementation targets and approaches to monitoring.

30+ years of media analysis of relevance to chronic disease: a scoping review.

BACKGROUND: Chronic, non-communicable diseases are a significant public health priority, requiring action at individual, community and population levels, and public and political will for such action. Exposure to media, including news, entertainment, and advertising media, is likely to influence both individual behaviours, and attitudes towards preventive actions at the population level. In recent years there has been a proliferation of research exploring how chronic diseases and their risk factors are portrayed across various forms of media. This scoping review aims to map the literature in this area to identify key themes, gaps, and opportunities for future research in this area. METHODS: We searched three databases (Medline, PsycINFO and Global Health) in July 2016 and identified 499 original research articles meeting inclusion criteria: original research article, published in English, focusing on media representations of chronic disease (including how issues are framed in media, impact or effect of media representations, and factors that influence media representations). We extracted key data from included articles and examined the health topics, media channels and methods of included studies, and synthesised key themes across studies. RESULTS: Our findings show that research on media portrayals of chronic disease increased substantially between 1985 and 2016. Smoking and nutrition were the most frequent health topics, and television and print were the most common forms of media examined, although, as expected, research on online and social media channels has increased in recent years. The majority of studies focused on the amount and type of media coverage, including how issues are framed, typically using content analysis approaches. In comparison, there was much less research on the influences on and consequences of media coverage related to chronic disease, suggesting an important direction for future work. CONCLUSIONS: The results highlight key themes across media research of relevance to chronic disease. More in-depth syntheses of studies within the identified themes will allow us to draw out the key patterns and learnings across the literature.

Key Performance Indicators for program scale-up and divergent practice styles: a study from NSW, Australia.

Implementing programs at scale has become a vital part of the government response to the continuing childhood obesity epidemic. We are studying the largest ever scale-up of school and child care obesity prevention programs in Australia. Health promotion teams support primary schools and early childhood services in their area to achieve a number of specified, evidence-based practices aimed at organizational changes to improve healthy eating and physical activity. Key performance indicators (KPIs) were devised to track program uptake across different areas-measuring both the proportion of schools and early childhood services reached and the proportion of practices achieved in each setting (i.e. the proportion of sites implementing programs as planned). Using a 'tight-loose-tight' model, all local health districts receive funding and are held accountable to reaching KPI implementation targets. However, local teams have independent discretion over how to best use funds to reach targets. Based on 12 months of ethnographic fieldwork and interviews across all districts, this study examines variations in the decision making and strategizing processes of the health promotion teams. We identified three distinct styles of practice: KPI-driven practice (strategic, focussed on targets); relationship-driven practice (focussed on long-term goals); and equity-driven practice (directing resources to sites most in need). In adapting to KPIs, teams make trade-offs and choices. Some teams struggled to balance a moral imperative to attend to equity issues, with a practical need to meet implementation targets. We discuss how models of program scale-up and tracking could possibly evolve to recognize this complexity.

Evidence suggests a need to rethink social capital and social capital interventions.

In the 21 years since social capital first appeared in the public health literature, the evidence base has grown enormously, now reaching 28 systematic reviews encompassing more than 850 individual studies. We summarise this evidence and explain why conclusions relating to both the relationship between social capital and health, and the effectiveness of interventions to promote population health remain elusive and contradictory. A critical factor is the inadequate way that context is treated in the research, and especially how context interacts with efforts to promote health in a dynamic fashion. Of all the different types of interventions one could employ to improve the health of the public, 'social capital' interventions are likely to be the most context specific and especially affected by the boundaries placed around the context. A way forward is offered that requires a combination of insights from systems thinking, community-based participatory research, and intervention and improvement sciences. This requires renewed focus on the specific components of social capital, an understanding of how context interacts dynamically with efforts to improve health, a greater role for practice in the design, implementation, adaptation and evaluation of interventions, and the support of researchers to develop better methods for recognising and classifying the knowledge generated by complex interventions.

Capturing implementation knowledge: applying focused ethnography to study how implementers generate and manage knowledge in the scale-up of obesity prevention programs.

BACKGROUND: Bespoke electronic information management systems are being used for large-scale implementation delivery of population health programs. They record sites reached, coordinate activity, and track target achievement. However, many systems have been abandoned or failed to integrate into practice. We investigated the unusual endurance of an electronic information management system that has supported the successful statewide implementation of two evidence-based childhood obesity prevention programs for over 5 years. Upwards of 80% of implementation targets are being achieved. METHODS: We undertook co-designed partnership research with policymakers, practitioners, and IT designers. Our working hypothesis was that the science of getting evidence-based programs into practice rests on an in-depth understanding of the role programs play in the ongoing system of local relationships and multiple accountabilities. We conducted a 12-month multisite ethnography of 14 implementation teams, including their use of an electronic information management system, the Population Health Information Management System (PHIMS). RESULTS: All teams used PHIMS, but also drew on additional informal tools and technologies to manage, curate, and store critical information for implementation. We identified six functions these tools performed: (1) relationship management, (2) monitoring progress towards target achievement, (3) guiding and troubleshooting PHIMS use, (4) supporting teamwork, (5) evaluation, and (6) recording extra work at sites not related to program implementation. Informal tools enabled practitioners to create locally derived implementation knowledge and provided a conduit between knowledge generation and entry into PHIMS. CONCLUSIONS: Implementation involves knowing and formalizing what to do, as well as how to do it. Our ethnography revealed the importance of hitherto uncharted knowledge about how practitioners develop implementation knowledge about how to do implementation locally, within the context of scaling up. Harnessing this knowledge for local use required adaptive and flexible systems which were enabled by informal tools and technologies. The use of informal tools also complemented and supported PHIMS use suggesting that both informal and standardized systems are required to support coordinated, large-scale implementation. While the content of the supplementary knowledge required to deliver the program was specific to context, functions like managing relationships with sites and helping others in the team may be applicable elsewhere.

Research on media framing of public policies to prevent chronic disease: A narrative synthesis.

Media coverage plays a key role in shaping public and political attitudes towards policy interventions to improve health. We reviewed studies of news media to identify the arguments used to frame policies that address risk factors for chronic disease, and the impact of different arguments on attitudes to policy. Drawing on a previous scoping review, we identified a subsample of 49 studies of media framing of policies to address risk factors for lifestyle-related chronic disease for further analysis. We extracted and synthesised data to explore key themes. Of the limited research that has been undertaken, most studies have focused on tobacco policy, followed by alcohol, with a small number of studies of food and beverage policies. Studies have primarily used content analysis. Our synthesis demonstrated that advocates and opponents draw on five frames: health, social, economic, practical and ideological. Only a small number of studies have examined the impact of framing on public attitudes towards policy interventions, although such studies have tended to focus on the impact of how problems, rather than solutions (i.e. policies) are framed. Media research is crucial to understanding the complex ways in which attitudes towards policy interventions shape, and are shaped by, public discourses and can provide public health advocates with insights into strategies to successfully position policy arguments. This review highlights key insights and gaps in the hope that this will stimulate further research that will enhance public health advocates' abilities to promote effective public health policy.

Variation in the operationalisation of dose in implementation of health promotion interventions: insights and recommendations from a scoping review.

BACKGROUND: While 'dose' is broadly understood as the 'amount' of an intervention, there is considerable variation in how this concept is defined. How we conceptualise, and subsequently measure, the dose of interventions has important implications for understanding how interventions produce their effects and are subsequently resourced and scaled up. This paper aims to explore the degree to which dose is currently understood as a distinct and well-defined implementation concept outside of clinical settings. METHODS: We searched four databases (MEDLINE, PsycINFO, EBM Reviews and Global Health) to identify original research articles published between 2000 and 2015 on health promotion interventions that contained the word 'dose' or 'dosage' in the title, abstract or keywords. We identified 130 articles meeting inclusion criteria and extracted data on how dose/dosage was defined and operationalised, which we then synthesised to reveal key themes in the use of this concept across health promotion interventions. RESULTS: Dose was defined in a variety of ways, including in relation to the amount of intervention delivered and/or received, the level of participation in the intervention and, in some instances, the quality of intervention delivery. We also observed some conflation of concepts that are traditionally kept separate (such as fidelity) either as slippage or as part of composite measures (such as 'intervention dose'). DISCUSSION: Dose is not a well-defined or consistently applied concept in evaluations of health promotion interventions. While current approaches to conceptualisation and measurement of dose are suitable for interventions in organisational settings, they are less well suited to policies delivered at a population level. Dose often accompanies a traditional monotonic linear view of causality (e.g. dose response) which may or may not fully represent the intervention's theory of how change is brought about. Finally, we found dose and dosage to be used interchangeably. We recommend a distinction between these terms, with 'dosage' having the advantage of capturing change to amount 'dispensed' over time (in response to effects achieved). Dosage therefore acknowledges the inevitable dynamic and complexity of implementation.

Knowledge mobilisation for chronic disease prevention: the case of the Australian Prevention Partnership Centre.

BACKGROUND: Cross-sectoral, multidisciplinary partnership research is considered one of the most effective means of facilitating research-informed policy and practice, particularly for addressing complex problems such as chronic disease. Successful research partnerships tend to be underpinned by a range of features that enable knowledge mobilisation (KMb), seeking to connect academic researchers with decision-makers and practitioners to improve the nature, quality and use of research. This paper contributes to the growing discourse on partnership approaches by illustrating how knowledge mobilisation strategies are operationalised within the Australian Prevention Partnership Centre (the Centre), a national collaboration of academics, policy-makers and practitioners established to develop systems approaches for the prevention of lifestyle-related chronic diseases. METHODS: We undertook interviews with key academics, policy, and practice partners and funding representatives at the mid-point of the Centre's initial 5-year funding cycle. We aimed to explore how the Centre is functioning in practice, to develop a conceptual model of KMb within the Centre for use in further evaluation, and to identify ways of strengthening our approach to partnership research. Inductive and deductive thematic analysis was used to identify the key mechanisms underpinning the Centre's KMb approach. RESULTS: Six key mechanisms appeared to facilitate KMb within our Centre, namely Engagement, Partnerships, Co-production, Capacity and Skills, Knowledge Integration, and Adaptive Learning and Improvement. We developed a conceptual model that articulated these mechanisms in relation to the structures and processes that support them, as well as the Centre's goals. Findings also informed adaptations designed to strengthen the Centre. CONCLUSIONS: Findings provide insights into the practical realities of operationalising KMb strategies within a research partnership. Overall, the centre is perceived to be progressing towards its KMb goals, but challenges include stakeholders from different settings understanding each other's contexts and working together effectively, and ensuring knowledge generated across different projects within the Centre is integrated into a more comprehensive understanding of chronic disease prevention policy and practice. Our conceptual model is now informing ongoing developmental evaluation activities within the Centre, where it is being tested and refined.

Communicating the benefits of population health interventions: The health effects can be on par with those of medication.

How can we communicate to the public that population level health interventions are effective at improving health? Perhaps the most familiar "currency" of effect is that which can be brought about via medication. Comparisons of effect sizes may be effective ways of communicating the benefits of population health interventions if they are seen and understood in the same way that medications are. We developed a series of comparisons to communicate benefits of population health interventions in terms of similar gains to be obtained from statins, metformin and antihypertensive medications for prevention of cardiovascular events, type 2 diabetes, obesity and hypertension. A purposive search identified evidence of population health intervention-related benefits. This evidence ranged from meta-analyses of RCTs to that from observational cohort studies. Population health interventions included implementation of national smoke free legislation, enhanced neighbourhood walkability, increased opportunities for active travel and protection of urban green space. In some cases, the benefits of population health interventions were found to be equivalent to, or even outweighed those of the medications to which they were compared. For example, RCT-based evidence suggested that exercise taken with a view of a green space was associated with 12 mmHg and 6 mmHg reductions in systolic and diastolic blood pressure, respectively, which was at least on par with the reductions associated with antihypertensive medications. Future work will test the effectiveness of these comparisons for increasing the familiarity, credibility and acceptability of population health interventions and, in particular, examine the importance of communicating putative mechanisms and potential co-benefits.

Will E-Monitoring of Policy and Program Implementation Stifle or Enhance Practice? How Would We Know?

Electronic or digital monitoring systems could promote the visibility of health promotion and disease prevention programs by providing new tools to support the collection, analysis, and reporting of data. In clinical settings however, the benefits of e-monitoring of service delivery remain contested. While there are some examples of e-monitoring systems improving patient outcomes, the smooth introduction into clinical practice has not occurred. Expected efficiencies have not been realized. The restructuring of team work has been problematic. Most particularly, knowledge from research has not advanced sufficiently because the meaning of e-monitoring has not been well theorized in the first place. As enthusiasm for e-monitoring in health promotion grows, it behooves us to ensure that health promotion practice learns from these insights. We outline the history of program monitoring in health promotion and the development of large-scale e-monitoring systems to track policy and program delivery. We interrogate how these technologies can be understood, noticing how they inevitably elevate some parts of practice over others. We suggest that progress in e-monitoring research and development could benefit from the insights and methods of improvement science (the science that underpins how practitioners attempt to solve problems and promote quality) as conceptually distinct from implementation science (the science of getting particular evidence-based programs into practice). To fully appreciate whether e-monitoring of program implementation will act as an aid or barrier to health promotion practice we canvass a wide range of theoretical perspectives. We illustrate how different theories draw attention to different aspects of the role of e-monitoring, and its impact on practice.