Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network

Body image attitudes and concerns among indigenous Fijian and European Australian adolescent girls

Research on body image has primarily been conducted among Western women who highly value the thin ideal body size. There has been limited research that has examined body image attitudes among Fijian adolescent girls who are exposed to both traditional sociocultural pressures that promote a larger body size and Western pressures that promote slimness. Using in-depth semi-structured interviews, we examined the factors associated with body image attitudes and concerns among a sample of 16 indigenous Fijian and 16 European Australian adolescent girls aged between 13–18 years. An inductive analysis of girls’ responses indicated that both groups of girls experienced body image concerns including body dissatisfaction, a preference for thinness and concerns associated with weight gain. These findings have implications for our understanding of the role of culture in shaping body image among girls and may prove useful in the development of future survey research that can be implemented among both Fijian and Western adolescents

A comparison of the sources and nature of body image messages perceived by indigenous Fijian and European Australian adolescent girls

Australian and Fijian adolescent girls reported on the influence that sociocultural factors, including parents, peers, and the media, had on their body image attitudes. It was expected that messages that promote a thin body would be less prevalent among Fijians, as their cultural traditions place more importance on robust body sizes. An inductive thematic analysis of the girls’ semi-structured interviews indicated that both Fijian (n = 16) and Australian (n = 16) girls (aged 13–17) reported messages from similar sources, which included parents, siblings, and friends/peers. Australian girls consistently reported messages that reinforced thinness. On the other hand, Fijian girls reported messages that emphasized both thinness and robustness. The discussion focuses on the conflict between Western ideals and cultural Fijian traditions and the implications for culturally sensitive interventions