ISSUE ADDRESSED:Food system sustainability is a broad goal, contributing to resilience, positive health, equity, cultural, environmental and economic outcomes. This study aims to understand the essential components on the journey towards "sustainable food systems" in New Zealand's, Hawke's Bay (HB) region. METHODS:Seventeen qualitative semi-structured interviews were conducted to identify barriers, facilitators and potential interventions for improving a sustainable food system. Cognitive mapping (CM) was utilised, generating causal links between themes to answer the question: "What would it take to enhance the HB region to sustain a resilient food ecosystem to supply local people with local food?" RESULTS:Three key themes were revealed: community engagement, the establishment of a local distribution system and fostering trust between growers and consumers. Community engagement was the most critical factor, highlighting the need for partnerships with local Iwi (tribe) and hapū (subtribe), support for local and community-based business models, economic sustainability and whakapapa of kai (genealogy of food) education. Establishing a local distribution system was identified as crucial to enhance the efficiency of food distribution and ensure repurposing of surplus food. Fostering trust between growers and consumers is needed to achieve this goal. CONCLUSIONS:These findings underscore the role of community-centric solutions in cultivating a sustainable food system. Rooted in the specific needs and aspirations of the community, the results offer valuable insights into the development of a sustainable food system in HB. SO, WHAT:Through leveraging cognitive mapping, this study provides a novel framework for enhancing community engagement and establishing a local distribution system.

Sickle cell disease (SCD) remains associated with reduced life expectancy and poor quality of life despite improvements observed in the last decades mostly related to comprehensive care, use of hydroxycarbamide, screening to identify patients at risk of strokes, and implementation of safe transfusion protocols. The course of the disease is highly variable, making it difficult to predict severity and response to therapy. Allogeneic hematopoietic stem cell transplantation potentially provides a cure with a relatively low rate of complications, but few patients have an HLA-identical sibling. The hopes of patients and healthcare providers have been raised after the initial excellent results of gene therapy studies. However, there is a strong contrast between the high expectations of families and patients and the limited availability of the product, which is technically complex and very expensive. In light of this consideration and of the limited data available on the long-term efficacy and toxicity of different gene therapy approaches, the European Hematology Association Red Cell & Iron Specialized Working Group (EHA SWG) and the hemoglobinopathy working part of the European Blood & Marrow Transplant (EBMT) Group have prioritized the development of recommendations for selection of patients with SCD who are good candidates for gene therapy. The decision-making algorithm was developed by a panel of experts in hemoglobinopathies and/or transplantation chosen by EHA SWG and EBMT, to discuss the selection of SCD patients for gene therapy and draw notes on the related clinical problems.

The nutritional health of tamariki (children) in Aotearoa New Zealand (NZ) is poor. Nourishing Hawke's Bay (NHB) began as an initiative to address this problem in low advantage regions of Hawke's Bay (HB) and evolved into the evaluation of Ka Ora. Ka Ako the free, healthy school lunch programme, and the scoping of wider improvements in the regional food ecosystem. The aim of this paper is to describe how NHB co-designed and evaluated food interventions incorporating systems thinking and mātauranga Māori (traditional knowledge), as lenses through which to view the initiative. Cognitive mapping interviews (n = 11) with community health and education leaders identified six key co-design principles or Pou (metaphorical posts) for NHB. Further systems methods, such as group model building and system dynamics modelling, and mātauranga Māori methods, such as wānanga (Māori learning forums), involved the community in food systems mapping and intervention co-design and prioritisation. Three Pou, 'food security,' 'mātauranga Māori' and 'children's hauora' (wellbeing), set the research agenda for NHB. the other three Pou, 'work with community,' 'cohesion and integration' and 'start with schools,' determined the subsequent research processes. Along with standard population evaluation methods (including quantitative and qualitative assessments of changes in student health and wellbeing), a participatory Value for Investment (VFI) analysis assessed return on investment. Combining systems thinking and mātauranga Māori is a novel, participatory approach co-creating pathways to improved nutrition and food security for tamariki and holds promise for wider food system changes in regional NZ.

The Ka Ora, Ka Ako school lunch programme introduced in 2020 provides nutritious lunches to around 220,000 students in low-advantage schools. While the food security impacts of this programme have been well documented, its potential to enhance outcomes in other areas of public policy is underappreciated. We conducted a policy analysis to map the programme’s intersection with current public policy agendas in education, sustainability and health in Aotearoa New Zealand. We conclude that Ka Ora, Ka Ako can be a powerful platform to effect broad societal outcomes through alignment with school curricula, concerted effort to reducecarbon emissions, and commitment to delivering highly nutritious foods to all students in qualifying schools.

Ka Ora, Ka Ako provides free, healthy lunches for 220,000 learners in low-equity New Zealand schools. Costing over $260 million annually, it represents the largest government investment in child nutrition in generations. Early evaluations indicate success in achieving programme aims of delivering nutritious food, improving learners’ wellbeing, and easing financial stress for families. However, international evidence and emerging local data indicate the programme can achieve the above and more. This article presents a programme logic model drawing on local data and a review of relevant international literature on universal school food provision with the aim of identifying potential long-term outcomes and impacts at multiple levels: for learners, wh`ānau, schools, communities, and food systems. Findings indicate that the Ka Ora, Ka Ako programme has the potential to:• improve children’s nutrition and educational outcomes, as well as improve child and wh`ānau food security;• enrich school learning environments; • boost local economies (through creation of jobs paying a living wage) and enhance local foodscapes (including availability and affordability of healthy foods) through food system engagement in schools, with whänau and communities; and• increase food system resilience (e.g., shorter supply chains and relationship building), and encourage broader food system transformation (e.g., reformulation, waste and packaging solutions) with leverage from new procurement models.While Ka Ora, Ka Ako can contribute to these pathways, some implementation areas within the programme demand further attention to achieve optimal results. Recognised areas for improvement include ensuring high quality of food, providing more avenues for engagement from children and parents, addressing perceived challenges to integrate Ka Ora, Ka Ako effectively with mātauranga Māori, and improving waste management. Given the high potential for Ka Ora, Ka Ako to contribute to multiple beneficial outcomes, continued investment and expansion of the programme is warranted.

Children’s nutrition is highly influenced by community-level deprivation and socioeconomic inequalities and the health outcomes associated, such as childhood obesity, continue to widen. Systems Thinking using community-based system dynamics (CBSD) approaches can build community capacity, develop new knowledge and increase commitments to health improvement at the community level. We applied the formal structure and resources of a Group Model Building (GMB) approach, embedded within an Indigenous worldview to engage a high deprivation, high Indigenous population regional community in New Zealand to improve children’s nutrition. Three GMB workshops were held and the youth and adult participants created two systems map of the drivers and feedback loops of poor nutrition in the community. Māori Indigenous knowledge (mātauranga) and approaches (tikanga) were prioritized to ensure cultural safety of participants and to encourage identification of interventions that take into account social and cultural environmental factors. While the adult-constructed map focused more on the influence of societal factors such as cost of housing, financial literacy in communities, and social security, the youth-constructed map placed more emphasis on individual-environment factors such as the influence of marketing by the fast-food industry and mental wellbeing. Ten prioritized community-proposed interventions such as increasing cultural connections in schools, are presented with the feasibility and likely impact for change of each intervention rated by community leaders. The combination of community-based system dynamics methods of group model building and a mātauranga Māori worldview is a novel Indigenous systems approach that engages participants and highlights cultural and family issues in the systems maps, acknowledging the ongoing impact of historical colonization in our communities.

Abstract Issue addressed Hawke's Bay has one of the highest rates of childhood obesity in New Zealand. While several initiatives exist aiming to decrease obesity through physical activity, there are few nutritional interventions. This study adopted a systems science and mātauranga Māori approach to identify and target underlying drivers of rising childhood obesity and engage the community to improve the food environment. Methods Cognitive mapping interviews (CM) with local stakeholders (school principals, Iwi and district health board representatives, education managers and local councillors) were conducted. The aim was to map participants’ mental models of the causes of rising childhood obesity and to identify key principles for engaging with the local community in a meaningful, impactful and culturally appropriate way for future action. Results Eleven interviews were conducted face‐to‐face and cognitive maps were constructed. Follow‐up interviews were carried out online, due to COVID restrictions, to present the maps and for interviewees to make any adjustments. Four composite themes emerged through centrality and cluster analysis of the resulting cognitive maps: the importance of building in mātauranga Māori (Māori knowledge and ways of being), the “hauora” of children, working with the community and integrating existing initiatives. Two contextual factors are also considered: the growing need for food security in our communities and the opportunity to start interventions in the school setting. Conclusion Cognitive mapping can produce useful insights in the early stages of community engagement. The six “pou” (pillars) underscore the importance of incorporating indigenous knowledge when embarking on public health interventions, particularly around obesity and in regional communities. So what? When designing a public health initiative with a community with a high indigenous population, indigenous knowledge should be promoted to focus on holistic health, working with the community and creating opportunities for cohesion. These founding principles will be used to structure future community actions to improve children's food environments in regional New Zealand.

As part of the COVID-19 economic recovery package, the Aotearoa New Zealand Government rolled out a universal free and healthy lunch programme to the 25% least advantaged schools nationwide. This study explored experiences of school lunch providers in the Hawke’s Bay region. The aim was to create a systems map identifying points of intervention through which the lunch programme could be improved to meet the goal of reducing child food insecurity. Twelve lunch providers were interviewed to generate casual loop diagrams which were examined and integrated to form a single systems map. Seven themes arose during analysis: teacher support, principal support, nutrition guidelines and government support, supply chain, ingredient suppliers, student feedback and food waste. Teacher support was important for getting students to try new foods and eat the nutritious lunches. Principal support was a strong theme impacting opportunities for broader student engagement. This study employed systems science to highlight the importance of support from different stakeholders within the lunch programme to achieve the goal of reduced child food insecurity. Further work is needed to ensure the programme meets the wider goals of the government and community, and to determine the potential broader benefits of the programme.

Systems Thinking is increasingly applied to address complex societal and public health issues in Aotearoa, New Zealand and has been proposed as a good fit with traditional wisdom and Mātauranga Māori (Indigenous knowledge) from Aotearoa, New Zealand. In this article, we delve into the theoretical underpinnings of Systems Thinking approaches used in Community-Based System Dynamics research and find parallels with Indigenous narratives and knowledge. The synergy created by combining these two knowledge systems and practices is proposed as an effective way to approach public health issues that emerge from complex adaptive systems, particularly in communities with large numbers of Indigenous peoples. Examples are given from an initiative to engage community to improve food security and nutrition in regional Aotearoa, New Zealand.

In 2016, the European Hematology Association (EHA) published the EHA Roadmap for European Hematology Research(1) aiming to highlight achievements in the diagnostics and treatment of blood disorders, and to better inform European policy makers and other stakeholders about the urgent clinical and scientific needs and priorities in the field of hematology. Each section was coordinated by one to two section editors who were leading international experts in the field. In the five years that have followed, advances in the field of hematology have been plentiful. As such, EHA is pleased to present an updated Research Roadmap, now including eleven sections, each of which will be published separately. The updated EHA Research Roadmap identifies the most urgent priorities in hematology research and clinical science, therefore supporting a more informed, focused, and ideally a more funded future for European hematology research. The eleven EHA Research Roadmap sections include Normal Hematopoiesis; Malignant Lymphoid Diseases; Malignant Myeloid Diseases; Anemias and Related Diseases; Platelet Disorders; Blood Coagulation and Hemostatic Disorders; Transfusion Medicine; Infections in Hematology; Hematopoietic Stem Cell Transplantation; CAR-T and Other Cell-based Immune Therapies; and Gene Therapy.

Methemoglobinemia is a rare disorder associated with oxidization of divalent ferro-iron of hemoglobin (Hb) to ferri-iron of methemoglobin (MetHb). Methemoglobinemia can result from either inherited or acquired processes. Acquired forms are the most common, mainly due to the exposure to substances that cause oxidation of the Hb both directly or indirectly. Inherited forms are due either to autosomal recessive variants in the CYB5R3 gene or to autosomal dominant variants in the globin genes, collectively known as HbM disease. Our recommendations are based on a systematic literature search. A series of questions regarding the key signs and symptoms, the methods for diagnosis, the clinical management in neonatal/childhood/adulthood period, and the therapeutic approach of methemoglobinemia were formulated and the relative recommendations were produced. An agreement was obtained using a Delphi-like approach and the experts panel reached a final consensus >75% of agreement for all the questions.

Group model building (GMB) is a qualitative method aimed at engaging stakeholders to collectively consider the causes of complex problems. Tackling inequities in community nutrition is one such complex problem, as the causes are driven by a variety of interactions between individual factors, social structures, local environments and the global food system. This methods paper describes a GMB process that utilises three system mapping tools in a study with members of a multicultural, low-income community to explore declining fruit and vegetable intake in children. The tools were: (1) graphs over time, which captures the community's understanding of an issue; (2) cognitive mapping, which enables participants to think systemically about the causes and consequences of the issue; (3) causal loop diagrams, which describe feedback loops that reinforce the issue and identify potential actions. Cognitive mapping, a tool not usually associated with GMB, was added to the research process to support the gradual development of participants' thinking and develops the skills needed to tackle an issue from a systems perspective. We evaluate the benefits and impact of these three tools, particularly in engaging participants and increasing understanding of systems thinking in order to develop and mobilise action. The tools could be adapted for use in other community-based research projects. Key learnings were the value of genuine partnership with a local organisation for longevity of the project, recruitment of key decisionmakers from the community early in the process, and allowing time to create sustainable change.

Introduction: Cases of sensitisation to platinum salts within platinum-processing sectors (particularly platinum refineries and motor-vehicle, catalytic-convertor production) have been extensively described. However, the occurrence of platinum-salt sensitisation outside of these sectors is less well known. We present a case of platinum-salt sensitisation in a chemical plant worker cleaning reactors from platinum refineries.Methodology: A 32-year-old man working at a chemical plant presented at the National Institute for Occupational Health's Occupational Medicine Clinic for evaluation of potential work-related asthma. A medical evaluation, including spirometry and a skin-prick test for sodium hexachloroplatinate and ammonium chloroplatinate salts (platinum salts), was performed.Results: The worker had convincing evidence of occupational asthma induced by platinum salts: there was a temporal association between lower respiratory symptoms and workplace exposure; he had objective evidence of asthma; and he had exposure to a known cause of occupational asthma, namely, platinum salts. Positive skin-prick tests to two platinum salts - an 11 mm wheal average for sodium hexachloroplatinate and a 10 mm wheal average for ammonium chloroplatinate - provided support that platinum salts were the causative agent.Conclusion: This case demonstrates that platinum-salt sensitisation and resultant allergic diseases can occur outside the traditional industries associated with exposure to platinum salts. Healthcare providers should be aware of this, and occupational health services need to prevent sensitisation through appropriate hazard control - in this case cleaning of reactors at the refinery - and to consider medical surveillance of exposed workers. Thorough workplace health-risk assessments are required to adequately identify potential exposures.

Many children globally do not meet government guidelines for daily fruit and vegetable intake, and in New Zealand, adherence to the vegetable intake recommendation is declining. This study aimed to identify systemic barriers to children meeting fruit and vegetable (FV) guidelines and generate sustainable actions within a local community to improve children's FV intake. A qualitative system dynamics method of community group model building was used. The research team partnered with Healthy Families Waitākere, a Ministry of Health funded prevention initiative, to recruit 17 participants (including students, parents, teachers, community leaders, local retailers and health promoters) from a low-income, ethnically-diverse community in West Auckland, New Zealand. Three group model building workshops were held during which a systems map was created and used to identify actions by considering causal pathways and reinforcing loops in the system. Barriers to children's FV intake identified by participants were the saturation of fast-food outlets in the community and ubiquitous marketing of these products, the high cost of fresh produce compared to fast food, and parents having little time for food preparation plus declining cooking skills and knowledge. Several actions to improve children's FV intake by improving the local food environment were identified, which will be co-designed further and tested by a collaborative group involving community leaders. This project highlights the effectiveness of group model building for engaging a local community in systems change to improve child nutrition, and supplies a blueprint for future qualitative system dynamics research.

Much has been written about the impact of chronic conditions on post-colonial indigenous populations. Much less, however, has been written about indigenous knowledge and how it may help tackle poor health statistics among indigenous populations. This article describes two approaches to obesity prevention that are grounded in Mātauranga Māori (Māori worldview), both of which challenge the “person-centred” approach so prevalent in Western approaches. These approaches were mapped using Systems Thinking tools, specifically causal loop diagrams, to test whether or not these tools could be used to “translate” indigenous approaches in a way that retained the integrity of their particular worldview and provided a tool to help those communities reflect on their practices in a way that led to new insights. Systems Thinking was found to have many overlaps with Mātauranga Māori, and the use of system thinking tools provided mutually beneficial learning opportunities for both the researchers and the communities involved.

Fruit and vegetable (FV) intake is declining in New Zealand, and over half of New Zealand's children do not meet the recommendation of two serves of fruit and three serves of vegetables daily (with even lower adherence among children in high-deprivation neighbourhoods). The aim of this study was to map the potential causal pathways explaining this decline and possible actions to reverse it. Semi-structured interviews were held in April-May 2018 with 22 national actors from the produce industry, food distribution and retail sector, government, and NGO health organisations. The qualitative systems dynamics method of cognitive mapping was used to explore causal relationships within the food system that result in low FV intake among children. Barriers and solutions identified by participants were analysed using thematic analysis and according to a public health intervention framework. Participants were in agreement with the goal of improving FV intake for health and economic outcomes, and that health promotion strategies had been ineffectual to date due to multiple systemic barriers. Common barriers discussed were poverty, high food prices, low skills/knowledge, unhealthy food environments, climate change, and urbanization. Solutions with the strongest evidence of efficacy identified by the participants were subsidizing FVs and early childhood interventions to improve FV exposure.

Transport is a vast and complex socio-technical system, and despite a clear need to reduce dependence on fossil fuels due to undesirable environmental impacts, it is largely locked into business-as-usual. Systems approaches are a useful way to help make sense of multiple competing influences which may be simultaneously driving change and supporting the status quo. This paper applies qualitative system dynamics modelling to help interpret the results of a Delphi study into global transport transitions, involving 22 international experts in various aspects of transport. The main contribution of the paper is its exploration of the use of system dynamics (SD) modelling to interpret the Delphi findings. SD modelling was used to reveal and elucidate the causal arguments put forward by the expert panel about the factors driving business-as-usual, the factors creating barriers to more sustainable transport systems, and the drivers of change. The SD model is used to explore and expose the key causal patterns at play, and how these interact to both support and hinder change. The resulting model shows the complex, interdependent dynamics involved in supporting the status quo. Even at the relatively high level of analysis reported here, the model is useful in revealing interdependencies between parts of the system, where change in one part may well have knock-on effects elsewhere in the system. In particular the model reveals the strong reinforcing loops that act to minimise the impact of change drivers and thus retain the dominance of automobility. The result is a system that is highly dependent on the continued existence of key reinforcements such as policies that subsidise fossil fuels. From a methodological perspective, the outcomes of the Delphi study provided a rich source of qualitative material which was highly suitable for developing a system dynamics model.