BACKGROUND:The World Health Organization (WHO) recommends six domains for a whole-school approach to promote physical activity (PA) levels. This approach aims to help children achieve 30 of the recommended 60 minutes of daily moderate-to-vigorous physical activity (MVPA). Evidence on PA practice and policy in school settings is limited, particularly in urban areas with high deprivation, where children's PA levels are lowest. METHODS:We developed a 20-item survey based on the WHO domains and distributed it to 1826 state-funded primary schools in all 32 Greater London boroughs between 6 November 2023 and 31 December 2024. We extracted survey items relating to each domain and calculated the percentage of schools reporting each practice. RESULTS:Our sample of 185 schools (10.1%) included at least one school from each borough and was broadly representative of school populations in Greater London, except that responding schools were more likely to have fewer pupils eligible for free school meals. Most schools (68.5%) reported implementing at least one practice aligned with each of the six WHO domains. Specifically, 98.4% reported providing curricular physical education (Domain 1), 78.9% had an active travel plan (Domain 2), 98.4% offered PA opportunities before/after school (Domain 3), 92.4% provided opportunities for PA during breaks (Domain 4), 81.7% incorporated PA into lessons (Domain 5), and 81.5% reported supporting the inclusion of pupils with additional needs in PA opportunities (Domain 6). However, implementation within domains varied; for example, only 53.5% met the nationally recommended two hours of physical education per week, with similarly low levels for before‑school PA provision and active travel initiatives. CONCLUSION:Most primary schools in this large, multi-ethnic urban sample reported school policies and practices aligned with WHO domains, suggesting that a whole-school approach to creating an active school environment is feasible to implement. However, we identified areas for improvement within domains, and alignment alone may be insufficient to meaningfully increase children's PA levels. This study provides a foundation for future research linking active school environments with children's PA and mental health, thereby informing efforts to increase MVPA and promote equitable outcomes.

Abstract Background School holidays can be a period of isolation and difficulty for children from low-income families. Limited opportunities for enrichment activities, and food insecurity, mean that children’s health and well-being can suffer. There is also potential learning loss, particularly during longer holiday periods. The Holiday Activities & Food (HAF) programme is a government-funded (> £200 M/y) initiative in England which aims to provide healthy meals and activities to free school meal (FSM)-eligible children during school holidays. Existing evaluations of the programme have identified varied provision across England, with challenges such as quality of delivery, engagement and attendance. Evidence is needed to understand how the programme could be improved, from the perspectives of those involved in delivery and families who attend. In this study we present data which addresses this gap and can inform relevant policy and practice. Method We purposively sampled participants from across the Southwest, Midlands and Northeast of England. Interviews were conducted with local government Political Leads ( n =5), HAF programme Leads ( n =11), HAF club Providers ( n =12), parents ( n =10), and children with Special Educational Needs and Disabilities (SEND; 9-12y; n =2). Primary school children (8-12y; n =15) participated in focus groups. Data were analysed using the Framework Method. HAF Leads ( n =9) completed an economic survey. Results Five key themes were identified: (1) Eligibility, reach and attendance: Open-access provision is needed to reduce stigma and improve attendance. (2) The importance of relationships: Families and communities need to work together; (3) Delivering a high-quality, inclusive HAF programme: there is a need for flexible choice-led provision; (4) Schools as trusted advocates: Schools can support reach and recruitment of the HAF programme; and (5) Evaluation of HAF: Current evaluations are insufficient and a comprehensive evaluation with children, families and communities is needed. Conclusion To ensure that families are receiving the support they need, we recommend that changes to the programme allow community organisations to have agency to decide how best to work with their families, achieved by greater flexibility within the national guidelines and criteria. Moreover, we recommend poverty-proofed , place-based holiday provision that is iteratively developed with the involvement of local families.

INTRODUCTION:School environments that encourage children to be physically active can embed lifelong positive health behaviours and contribute towards reducing health inequalities. The Health and Activity of Pupils in the Primary Years (HAPPY) study aims to: (1) explore the extent to which the WHO criteria for creating active school environments are implemented by primary schools and (2) examine associations between active school environments and children's physical activity, mental health and educational performance. METHODS AND ANALYSIS:The HAPPY study is a quasi-experimental study comprising: (1) a survey of state-funded Greater London primary schools to identify implementation of the WHO's six criteria and (2) a cross-sectional study to examine associations between schools' active environment score (derived from the school survey) and pupils' physical activity, mental health and educational performance. For our cross-sectional study, we will recruit up to 1000 year-three children (aged 7-8 years). Our primary outcome is accelerometer (GENEActiv) assessed physical activity, our secondary outcomes are parent-reported child mental health (Strengths and Difficulties Questionnaire) and teacher-reported educational performance (age-related expectations). Using multilevel mixed-effects regression models, we will examine associations between the active environment score and physical activity. Physical activity will be included as a measure of acceleration and also different intensities (light, moderate, vigorous). We will repeat this analysis to examine associations between the active environment score and mental health and educational performance. We will adjust for school characteristics and area-level deprivation and include pupil characteristics (eg, sex, ethnic group) as covariates. Clustering at the school level will be included as a random effect. ETHICS AND DISSEMINATION:Ethical approval has been obtained from Imperial College Research Ethics Committee (ref: 6800895). Findings will be disseminated through a summary report to all participating schools, peer-reviewed publications, presentations at national and international conferences and National Institute for Health and Care Research policy briefings.

Children with special educational needs and disabilities (SEND), particularly those from families with low-income, experience inequities across educational and health outcomes. The school holidays are difficult for families with low-income, prompting UK government programmes including the Holiday Activity and Food (HAF) clubs. Little is known about how inclusive these holiday clubs are for children with SEND, despite this being a group who may particularly benefit. This study is embedded within a wider project on the HAF programme to explore the challenges and opportunities for inclusive and accessible holiday club provision and provides recommendations for the HAF Toolkit. Participant experiences were captured using two qualitative methods: 1) interviews with holiday programme delivery staff and parents of attendees (staff n=28, parents n=10); 2) focus group discussions at creative workshops with parents whose children are eligible for the holiday programme but do not attend (n=22). The Framework Method and Reflexive Thematic Analysis were used. Participant experiences were captured using two qualitative methods: (1) interviews with holiday programme delivery staff and parents of attendees (staff n = 28, parents n = 10); (2) focus group discussions at creative workshops with parents whose children are eligible for the holiday programme but do not attend (n = 22). The Framework Method and Reflexive Thematic Analysis were used. Findings reveal challenges and opportunities around accessing and experiencing the holiday clubs for children with SEND. Access subthemes included: lack of clarity in advertising whether clubs welcome children with SEND; frequent non-disclosure from parents of their child’s needs; accessible transportation; and additional resources needed for SEND provision. Experience subthemes included: food provision for children with SEND; training and staffing that covers the range of needs; and the experiences of children within mainstream provision versus specialist providers of SEND clubs. All participant groups illuminated areas where holiday clubs could be improved to ensure an enjoyable and equitable experience for children with SEND. However, wider debates around ableism and the challenges children with SEND face in society broadly were also illustrated in data. Further, the current economic context and the additional resources needed to support inclusive holiday club provision underpinned much of the data. Opportunities were highlighted such as parent volunteers and external investment, that could maximise the potential of the current government funding. Our findings highlight issues in access and experience of holiday clubs for children with SEND and provide potential avenues for promoting inclusivity, including how adaptations to the Toolkit could specifically improve HAF. There are considerable challenges to achieving inclusive holiday clubs (financial or otherwise) but if we are to reduce inequities, addressing these should be a public health priority.

Background:Public health attempts to prevent obesity in children and young people should aim to minimize health inequalities. Two Cochrane reviews examining interventions aiming to prevent childhood obesity found that interventions promoting (only) physical activity have a small beneficial effect on BMI for people aged 5-18 years, as do interventions promoting physical activity alongside healthy eating for 5-11 year olds. We examined whether the effectiveness of the interventions included in these reviews differed according to eight factors associated with inequity: place, race/ethnicity, occupation, gender/sex, religion, education, socio-economic status, and social capital (the PROGRESS framework). Methods:We collected data on change in BMI (standardized or unstandardized), subgrouped by baseline measures of PROGRESS factors, for intervention and control groups, from trial authors. We calculated the intervention effect per subgroup (mean difference), then contrasted these to estimate interactions between intervention and the baseline factors. We combined interaction estimates for each factor across trials using meta-analyses. Findings:We collected subgrouped data from 81 trials that took place between 2001 and 2020, involving 84,713 participants. We found no substantial differences in effectiveness of interventions for PROGRESS subgroups in most scenarios. However, in the younger age group (5-11 years), the effect of interventions on standardized BMI appeared to be higher in boys (average difference in mean differences 0.03; 95% CI 0.01 to 0.06; 45 studies, n = 44,740), which was consistent in direction with the BMI effect (average difference in mean differences 0.06 kg/m2; 95% CI -0.02 to 0.13; 31 studies, n = 27,083). Interpretation:Our findings suggest that those responsible for public health can promote these beneficial interventions without major concerns about increasing inequalities but should be mindful that these interventions may work better in boys aged 5-11 years than girls. More data are needed, so we encourage future trialists to perform subgroup analyses on PROGRESS factors. Funding:National Institute for Health and Care Research (NIHR).

Understanding the lived experience of communities of people who are most affected by health inequalities has become a key focus of public health research. In this context, researchers are increasingly using creative (or arts-based) methods, but there is limited understanding about how best to facilitate these methods to qualitative inquiry that illuminate lived experience and the values that underpin this approach. This paper reports the reflections of researchers who used creative facilitation (a set of tools) in workshops, as part of a research project, which explored how children and families across England, living in poverty, experience the school holidays, including leisure during school holidays. Two professional creative facilitators delivered a two-day training course for the research team in advance of the workshops. Following the workshops, the researchers and facilitators took part in focus groups and a survey which captured their reflections on using creative facilitation. Creative facilitation was deemed to generate new insights on school holiday experiences, providing a greater depth of nuance and understanding and more meaningful and person-centred data. Three key aspects of creative facilitation were identified. First, creating a welcoming research environment, underpinned by positive relationships, where there is trust and an authentic focus on participant choice, comfort, value, empowerment, inclusion and diversity. Second, promoting unconditional positive regard and an ethics of care; the tension between adhering to ethics procedures at the start of the workshop when trying to create a welcoming environment was highlighted as a significant challenge. Third, being adaptive and responsive during the session; the level of flexibility needed during the workshops was challenging, and sometimes uncomfortable, for researchers. Researchers reflected that further experience, ongoing support, and rethinking the ‘scaffolding’ of their approach, would develop their capability in the longer term. We offer suggestions for future activity around creative facilitation for public health research.

The components of integrated care for children, young people and families (CYPF) listed across existing authoritative guidance is generally consistent; the guidance suggests a list of components that should ideally be considered for implementation. Local system managers report specific challenges around integrating system-wide funding, trusted workforce relationships, and CYPF engagement. We aimed to systematically generate a list of components of integrated care from existing systems and models for CYPF, assess their commonality, intended target(s) of impact, and compare these findings with guidance and local system managers’ concerns. PubMed, CINHAL and Cochrane CENTRAL were systematically searched (01/01/2016 to 31/12/2023) for studies of any design, conducted in high-income countries, describing components of an integrated care system or model for CYPF. Following data extraction, individual components within studies were coded a) using the framework method to generate Component Themes b) for their intended target(s) of impact; system (S), users (U) and/or workforce (W). Simple analytic methods were used to rank and map the commonality of Component Themes and their intended target(s) of impact. Subgroup analysis was conducted for four public health priorities: mental health, learning disabilities and autism, obesity, and early years. From 170 studies, 1057 components nested in one or more 25 Component Themes of integration were identified. None of the studies identified all Component Themes (median 5, range 1–16). Most commonly identified were ‘shared professional responsibility and practices’ (in 58

Childhood obesity inequalities in England persist despite targeted interventions focused on promoting healthy diets and food environments. This study, part of the Family Food Experience Study-London, aimed to investigate the impact of deprivation and neighbourhood food environments on home food environments, parental feeding practices, child eating behaviours, food preferences, and child BMI. Families (n = 728) with primary school-aged children were recruited from four socioeconomically diverse London boroughs in 2022. Data were collected through computer-assisted interviews (30.8

Background Excess weight remains a concern for preschool-aged children. To support action in practice, we synthesised systematic review evidence assessing determinants of health behaviours in 0-6-year-olds to inform the co-production of health promotion materials to promote UK preschoolers’ healthy weight. Methods Phase 1: Synthesis of review-level evidence on dietary (i.e. fruit and vegetable, obesogenic food and sugar-sweetened beverage consumption), feeding (i.e. portion size), and movement behaviours (i.e. physical activity and sedentary behaviour) (Spring 2024). Determinants (assessed in cross-sectional, longitudinal and intervention studies) and their direction of association with each behaviour were extracted and synthesised according to the socio-ecological model (i.e. individual, interpersonal, organisational and environmental domains). Phase 2: Phase 1 findings informed five co-design webinars with policy and practice partners, healthcare practitioners and childcare providers (‘interest holders’), co-producing a range of materials to promote healthy behaviours (launched Spring 2025). Results Twenty-nine determinants were associated with two or more health behaviours [individual (n = 8); interpersonal (n = 11); organisational (n = 6); and environmental (n = 4) domains]. Interpersonal determinants (e.g. relating to parents, siblings, other carers) were assessed often and tended to be positively associated with movement and dietary behaviours. Co-design webinars with 51 interest-holders, whose key priorities included supporting healthy weight and promoting physical activity/ healthy food availability, resulted in co-production of a free-to-use infographic; four animations; social media stills and dominos (for children). Conclusions Common determinants of preschoolers’ health behaviours were leveraged to co-develop health promotion materials, incorporating interest-holders’ key priorities. Child-friendly outputs, with diverse representations of families, were co-produced to support UK preschoolers’ healthy weight.

Background:Recent systematic reviews and meta-analyses on the effects of interventions to prevent obesity in children aged 5-18 years identified over 200 randomised trials. Interventions targeting diet, activity (including physical activity and sedentary behaviours) and both diet and activity appear to have small but beneficial effects on average. However, these effects varied between studies and might be explained by variation in characteristics of the interventions, for example, by the extent to which the children enjoyed the intervention or whether they aim to modify behaviour through education or physical changes to the environment. Here we develop a novel analytic framework to identify key intervention characteristics considered likely to explain differential effects. Objectives:To describe the development of the analytic framework, including the involvement of school-aged children, parents, teachers and other stakeholders, and to present the content of the finalised analytic framework and the results of the coding of the interventions. Design and methods:We first conducted a literature review to find out from the existing literature what different types of characteristics of interventions we should be thinking about and why. This information helped us to develop a comprehensive map (called a logic model) of these characteristics. We then used this logic model to develop a list of possible intervention characteristics. We held a series of workshops with children, parents, teachers and public health professionals to refine the list into a coding scheme. We then used this to code the characteristics of each intervention in all the trials which aimed to prevent obesity in children aged 5-18 years. Findings:Our finalised analytic framework included 25 questions across 12 characteristics. These addressed aspects such as the setting of the intervention (e.g. at school, at home or in the community), mode of delivery (e.g. to individuals or to groups of children), whether the intervention targeted diet and/or activity, complexity (e.g. focused on a single swap of juice for water or aimed to change all aspects of the diet), intensity, flexibility, choice, mechanism of action (e.g. through participation, education, change in the social environment, change in the physical environment), resonance (e.g. credibility of the person delivering the intervention), commercial involvement and the 'fun factor' (as perceived by children). We coded 255 interventions from 210 randomised trials. Conclusions:Our evidence-based analytic framework, refined by consulting with stakeholders, allowed us to code 255 interventions aiming to prevent obesity in children aged 5-18 years. Our confidence in the validity of the framework and coding results is increased by our rigorous methods and, especially, the involvement of children at multiple stages. Future work:Future work will include the development of statistical methods for the synthesis and its application to the data coded according to the analytic framework. Limitations:The coding results depend on the level of detail provided to describe the interventions, and the applicability of the analytic framework may be limited by demographic profile of the children and young people involved in the project. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131572.

BACKGROUND:Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. OBJECTIVES:To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. SEARCH METHODS:We used standard, extensive Cochrane search methods. The latest search date was February 2023. SELECTION CRITERIA:Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. DATA COLLECTION AND ANALYSIS:We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS:This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect. AUTHORS' CONCLUSIONS:The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.

BACKGROUND:Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. OBJECTIVES:To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. SEARCH METHODS:We used standard, extensive Cochrane search methods. The latest search date was February 2023. SELECTION CRITERIA:Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. DATA COLLECTION AND ANALYSIS:We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS:This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability. AUTHORS' CONCLUSIONS:The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

eToyBox merupakan platform pembelajaran dalam talian untuk guru prasekolah bagi meningkatkan literasi kesihatan dan seterusnya memperbaiki tingkah laku kanak-kanak yang berkaitan obesiti. Penilaian terhadap literasi digital, penerimaan bahan pendidikan digital, dan cabaran penggunaan program pendidikan berasaskan internet diperlukan sebelum pembangunan eToyBox. Seramai 54 orang guru prasekolah Jabatan Kemajuan Masyarakat (KEMAS) di Kuala Lumpur, Selangor, dan Sarawak yang terlibat dalam fasa intervensi ToyBox Study Malaysia pada tahun 2018 telah menyertai kajian keratan rentas ini. Soal selidik dalam talian diedarkan untuk menilai maklumat sosiodemografi, penggunaan alat komunikasi dan media, dan pandangan guru tentang penyesuaian modul ToyBox kepada bahan pendidikan digital. Subjek telah dihubungi, dan pautan soal selidik dikongsi melalui aplikasi WhatsApp. Kebanyakan subjek (74.0%) adalah perempuan Melayu dengan umur purata 37.7 ± 7.9 tahun. Kebanyakan subjek mempunyai akses internet (94.4%) dan memiliki sekurang-kurangnya telefon pintar, komputer riba atau tablet (94.4%). Majoriti subjek (75.0%) melaporkan kecekapan penggunaan teknologi pada tahap sederhana. Jumlah 65.0% subjek menilai kemahiran mereka dalam pemproses perkataan dan emel pada tahap mahir atau lebih tinggi; namun, hanya 22.0% dilaporkan untuk kemahiran hamparan elektronik lejar. Halangan utama untuk mengakses bahan pendidikan dalam talian ialah gangguan internet (74.1%). Kebanyakan subjek (90.0%) menyokong penyesuaian modul kepada pembelajaran dalam talian dan yakin bahawa ini akan memberi manfaat terhadap pembangunan profesional dan amalan pengajaran guru prasekolah. Kesimpulannya, majoriti subjek mempunyai tahap literasi digital yang sederhana dan bersedia menjalani pembelajaran serta pengajaran dalam talian. Hasil kajian ini boleh memberi panduan kepada pembangunan bahan pembelajaran dalam talian untuk guru prasekolah di Malaysia pada masa hadapan.

Effect sizes from previously reported trials are often used to determine the meaningful change in weight in childhood obesity prevention interventions because information on clinically meaningful differences is lacking. Estimates from previous trials may be influenced by statistical significance; therefore, it is important that they have a low risk of type 1 error. A systematic review and meta-analysis were conducted to report on the design of child obesity prevention randomized controlled trials and effectiveness according to risk of type 1 error. Eighty-four randomized controlled trials were identified. A large range of assumptions were applied in the sample size calculations. The most common primary outcome was BMI, with detectable effect size differences used in sample size calculations ranging from 0.25 kg/m 2 (followed up at 2 years) to 1.1 kg/m 2 (at 9 months) and BMI z-score ranging from 0.1 (at 4 years) to 0.67 (at 3 years). There was no consistent relationship between low risk of type 1 error and reports of higher or lower effectiveness. Further clarity of the size of a meaningful difference in weight in childhood obesity prevention trials is required to support evaluation design and decision-making for intervention and policy. Type 1 error risk does not appear to impact effect sizes in a consistent direction.

Abstract Background Improving the public’s understanding of how regional and socioeconomic inequalities create and perpetuate inequalities in health, is argued to be necessary for building support for policies geared towards creating a more equal society. However, research exploring public perceptions of health inequalities, and how they are generated, is limited. This is particularly so for young people. Our study sought to explore young people’s lived experiences and understandings of health inequalities. Methods We carried out focus group discussions (n = 18) with 42 young people, aged 13–21, recruited from six youth organisations in England in 2021. The organisations were located in areas of high deprivation in South Yorkshire, the North East and London. Young people from each organisation took part in three interlinked focus group discussions designed to explore their (i) perceptions of factors impacting their health in their local area, (ii) understandings of health inequalities and (iii) priorities for change. Due to the Covid-19 pandemic, most discussions took place online (n = 15). However, with one group in the North East, we carried out discussions face-to-face (n = 3). Data were analysed thematically and we used NVivo-12 software to facilitate data management. Results Young people from all groups demonstrated an awareness of a North-South divide in England, UK. They described how disparities in local economies and employment landscapes between the North and the South led to tangible differences in everyday living and working conditions. They clearly articulated how these differences ultimately led to inequalities in people’s health and wellbeing, such as linking poverty and employment precarity to chronic stress. Young people did not believe these inequalities were inevitable. They described the Conservative government as prioritising the South and thus perpetuating inequalities through uneven investment. Conclusions Our study affords important insights into young people’s perceptions of how wider determinants can help explain the North-South health divide in England. It demonstrates young people’s contextualised understandings of the interplay between spatial, social and health inequalities. Our findings support calls for pro-equity policies to address the structural causes of regional divides in health. Further research, engaging young people in deliberative policy analysis, could build on this work.

Objective: To identify effective characteristics of behaviour change (physical activity and diet) interventions that prevent obesity in children aged 5 to 18 years. Design: A Bayesian multi-level meta-regression analysis of randomized trial results, with intervention and trial characteristics coded according to an analytic framework co-developed with stakeholders. Data source: Two Cochrane systematic reviews of the effects of interventions to prevent obesity in children, 5 to 11 years and 12 to 18 years, both updated in 2024. Main outcome measures: Mean difference (MD) in change from baseline in age- and sex- standardized BMI measured as a Z-score (zBMI). Results that had been reported as (unstandardized) BMI or BMI percentile were converted to zBMI using bespoke mapping techniques. Results: We included 204 trials (255 intervention arms) reporting data on at least one of the main outcome scales. Interventions were effective on average (MD in zBMI −0.037, 95% credible interval −0.053 to −0.022). The greatest effects were associated with medium term follow-up (9 to <15 months) and older children (12 to 18 years). We found evidence of small but beneficial effects for interventions targeting physical activity alone compared with diet alone (difference in MDs −0.227, −0.362 to −0.090) and small unfavorable effects for interventions that involved a change to the structural environment (the majority of changes were in the school food environment) (difference in MDs 0.05, 0.017 to 0.085). Accounting for interactions between covariates, we found that the most effective combination of intervention characteristics was to intervene in the school setting, with an individualized element to delivery, targeting physical activity, using multiple strategies of short duration and high intensity, and involving modification of behaviour through participation in activities. Conclusions: The most effective characteristic to include in a behaviour change intervention to prevent obesity in children aged 5-18 years was targeting of physical activity. This should not be interpreted as evidence that attempts to modify diet are not beneficial. Being physically active and consuming a healthy diet during childhood offer many important benefits beyond contributing to healthy weight and growth. Our findings suggest that interventions to prevent obesity in children should consider focusing primarily on the promotion of physical activity and consider other effective characteristics we identify here. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Protocols [https://research-information.bris.ac.uk/ws/portalfiles/portal/373709759/Analysis\_plan\_final.pdf][1] ### Funding Statement This work was funded by the National Institute for Health and Care Research (NIHR) Public Health Programme (grant number NIHR131572). FS, DMC, JS and JPTH were supported in part by the NIHR Bristol Evidence Synthesis Group. JPTH, JS and THMM were supported in part by the NIHR Applied Research Collaboration West (ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust. ALD was supported in part by her Engineering and Physical Sciences Council (EPSRC) fellowship EP/Y007905/1. JPTH is a NIHR Senior Investigator (grant number NIHR203807). The views expressed in this paper are those of the authors and do not necessarily reflect those of the NIHR or Department of Health and Social Care. The funder had no role in the study design, analysis, interpretation, writing of the report or decision to submit the article for publication. All authors had full access to the data and can take responsibility for the integrity of the data and the accuracy of the data analysis. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: studies identified and described in the Cochrane systematic reviews: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015328.pub2/full https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015330.pub2/full I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data and codes that support the findings of this study are available at the GitHub repository: https://github.com/AnnieDavies/Obesity_Synthesis [1]: https://research-information.bris.ac.uk/ws/portalfiles/portal/373709759/Analysis_plan_final.pdf

Background Intersecting socioeconomic and demographic reasons for physical activity (PA) inequalities are not well understood for young people at risk of experiencing marginalisation and living with disadvantage. This study explored young people’s experiences of PA in their local area, and the associated impacts on opportunities for good physical and emotional health and wellbeing. Methods Seven local youth groups were purposefully sampled from disadvantaged areas across urban, rural and coastal areas of England, including two that were specifically for LGBTQ + young people. Each group engaged in three interlinked focus groups which explored young people’s perceptions and lived experience of PA inequalities. Data were analysed using an inductive, reflexive thematic approach to allow for flexibility in coding. Results Fifty five young people aged 12–21 years of different sexualities, gender and ethnicity took part. Analysis yielded four themes: PA experiences across spaces; resigned to a lack of inclusivity and ‘belonging’; safety first; complexities in access and accessibility. Young people felt more comfortable to be active in spaces that were simpler to navigate, particularly outdoor locations largely based in nature. In contrast, local gyms and sports clubs, and the school environment in general, were spoken about often in negative terms and as spaces where they experienced insecurity, unsafety or discomfort. It was common for these young people to feel excluded from PA, often linked to their gender and sexuality. Lived experiences or fears of being bullied and harassed in many activity spaces was a powerful message, but in contrast, young people perceived their local youth club as a safe space. Intersecting barriers related to deprivation, gender and sexuality, accessibility, disability, Covid-19, affordability, ethnicity, and proximity of social networks. A need emerged for safe spaces in which young people can come together, within the local community and choose to be active. Conclusions The overarching concept of ‘physical activity insecurity’ emerged as a significant concern for the young people in this study. We posit that PA insecurity in this context can be described as a limited or restricted ability to be active, reinforced by worries and lived experiences of feeling uncomfortable, insecure, or unsafe.

Inequalities in diets contribute to overall inequalities in health. Economic inequality and inequalities in access to healthy food are key drivers of poor diet and ill health among young people (YP). Despite mounting evidence of structural barriers to healthy eating, less is known about how YP view and experience these inequalities where they live, and how to address them. To explore YP's perspectives on the drivers of diet-related health inequalities, we conducted three interlinked focus groups with YP aged 13-21 years from six youth groups across three geographical areas in England. We analysed the data inductively and deductively using reflexive thematic analysis and generated themes by examining how social structure, context and agency interact and impact YP's diet. YP were aware of how inequalities in employment conditions impact their families' income and ability to eat a healthy diet. They cited the high availability of hot food takeaways in their local areas as a significant barrier to healthy eating but did not support closing or restricting these outlets. They held strong views on policies to tackle diet inequality and showed a nuanced understanding of the strengths and limitations of universal and targeted approaches. Our study showed that YP have an awareness and understanding of food as important in relation to health, and of diet-related inequalities. However, further efforts are needed to shape and promote policies that resonate with YP and address both their health and wider social concerns.

Integrated care has become a central feature of health system reform worldwide. In England, Integrated Care Systems (ICS) are intended to improve integration across public health, the National Health Service (NHS), education and social care. By April 2021, England had been divided into 42 geographical areas, each tasked with developing local ICS provision. However, it was not clear how ICSs would address the specific needs of children and young people (CYP). This study elicited the views of senior professional stakeholders in the first year of the ICS national roll out, to learn how integrated care for CYP was being implemented within the ICSs and future plans for service provision. A qualitative analysis of in-depth interviews with stakeholders, including healthcare professionals, NHS managers and local authority leaders (n = 25) selected from a diverse sample of ICSs (n = 7) across England, conducted during winter 2021/22. Reflexive thematic analysis involving a collaborative coding approach was used to analyse interview transcripts. Four themes were identified, indicating challenges and opportunities for ICSs in relation to the health of CYP: 1) Best start in life (a more holistic approach to health afforded by integrated care); 2) Local and national contexts (tensions between local and national settings and priorities); 3) Funding and planning (instituting innovative, long-term plans using limited existing CYP funding streams); 4) Organisational complexities (integrating the work of diverse organisations). The views of stakeholders, provided at the beginning of the journey towards developing local ICS CYP provision, revealed a common aspiration to change focus from provision of acute, largely adult-orientated services towards one with a broader, population health remit, including prevention and early intervention. This would be delivered by integration of a range of local services, including health, education, housing and social care, to set CYP on a life-long path towards improved health and wellbeing. Yet there was an awareness that change would take place over time within existing national policy and funding frameworks, and would require overcoming organisational barriers through further developing local collaborations and partnerships. As ICSs mature, the experiences of stakeholders should continue to be canvassed to identify practical lessons for successful CYP integrated care.