Preventing and reducing childhood and adolescent obesity is a growing priority in many countries. Recent UK data suggest that children in more deprived areas have higher rates of obesity and poorer diet quality than those in less deprived areas. As adolescents spend a large proportion of time in school, interventions to improve the food environment in and around schools are being considered. Nutrient standards for school meals are mandatory in the UK, but many secondary pupils purchase foods outside schools at break or lunchtime that may not meet these standards. Qualitative interviews were conducted with fast food shop managers to explore barriers to offering healthier menu options. Recruitment targeted independently-owned shops near secondary schools (pupils aged c.12-17) in low-income areas of three Scottish cities. Ten interviews were completed, recorded, and transcribed for analysis. An inductive qualitative approach was used to analyse the data in NVivo 10. Five themes emerged from the data: pride in what is sold; individual autonomy and responsibility; customer demand; profit margin; and neighbourhood context. Interviewees consistently expressed pride in the foods they sold, most of which were homemade. They felt that healthy eating and general wellbeing are the responsibility of the individual and that offering what customers want to eat, not necessarily what they should eat, was the only way to stay in business. Most vendors felt they were struggling to maintain a profit, and that many aspects of the low-income neighbourhood context would make change difficult or impossible. Independent food shops in low-income areas face barriers to offering healthy food choices, and interventions and policies that target the food environment around schools should take the neighbourhood context into consideration.

While widespread lip service is given in the UK to the social determinants of health (SDoH), there are few published comparisons of how the UK's devolved jurisdictions 'stack up', in terms of implementing SDoH-based policies and programmes, to improve health equity over the life-course. Based on recent SDoH publications, seven key societal-level investments are suggested, across the life-course, for increasing health equity by socioeconomic position (SEP). We present hard-to-find comparable analyses of routinely collected data to gauge the relative extent to which these investments have been pursued and achieved expected goals in Scotland, as compared with England and Wales, in recent decades. Despite Scotland's longstanding explicit goal of reducing health inequalities, it has recently been doing slightly better than England and Wales on only one broad indicator of health-equity-related investments: childhood poverty. However, on the following indicators of other 'best investments for health equity', Scotland has not achieved demonstrably more equitable outcomes by SEP than the rest of the UK: infant mortality and teenage pregnancy rates; early childhood education implementation; standardised educational attainment after primary/secondary school; health care system access and performance; protection of the population from potentially hazardous patterns of food, drink and gambling use; unemployment. Although Scotland did not choose independence on September 18th, 2014, it could still (under the planned increased devolution of powers from Westminster) choose to increase investments in the underperforming categories of interventions for health equity listed above. However, such discussion is largely absent from the current post-referendum debate. Without further significant investments in such policies and programmes, Scotland is unlikely to achieve the 'healthier, fairer society' referred to in the current Scottish Government's official aspirations for the nation.

The OPREVENT2 obesity prevention trial was a multilevel multicomponent (MLMC) intervention implemented in rural Native American communities in the Midwest and Southwest U.S. Intervention components were delivered through local food stores, worksites, schools, community action coalitions, and by social and community media. Due to the complex nature of MLMC intervention trials, it is useful to assess participants’ exposure to each component of the intervention in order to assess impact. In this paper, we present a detailed methodology for evaluating participant exposure to MLMC intervention, and we explore how exposure to the OPREVENT2 trial impacted participant diet quality. There were no significant differences in total exposure score by age group, sex, or geographic region, but exposure to sub-components of the intervention differed significantly by age group, sex, and geographical region. Participants with the highest overall exposure scores showed significantly more improvement in diet quality from baseline to follow up compared to those who were least exposed to the intervention. Improved diet quality was also significantly positively associated with several exposure sub-components. While evaluating exposure to an entire MLMC intervention is complex and imperfect, it can provide useful insight into an intervention’s impact on key outcome measures, and it can help identify which components of the intervention were most effective.

Native American populations experience highly disproportionate rates of poor maternal-child health outcomes. The WIC program aims to safeguard health by providing greater access to nutritious foods, but for reasons not well understood, participation in many tribally-administered WIC programs has declined to a greater extent compared to the national average decline in participation over the last decade. This study aims to examine influences on WIC participation from a systems perspective in two tribally-administered WIC programs. In-depth interviews were conducted with WIC-eligible individuals, WIC staff, tribal administrators, and store owners. Interview transcripts underwent qualitative coding, followed by identifying causal relationships between codes and iterative refining of relationships using Kumu. Two community-specific causal loop diagrams (CLDs) were developed and compared. Findings from interviews in the Midwest yielded a total of 22 factors connected through 5 feedback loops, and in the Southwest a total of 26 factors connected through 7 feedback loops, resulting in three overlapping themes: Reservation and Food Store Infrastructure, WIC Staff Interactions and Integration with the Community, and State-level Administration and Bureaucracy. This study demonstrates the value of a systems approach to explore interconnected barriers and facilitators that can inform future strategies and mitigate declines in WIC participation.